Mikheil Saakashvili
 - Question

Lord Harries of Pentregarth: To ask Her Majesty’s Government what representations they are making to the government of Georgia about the continued imprisonment of Mikheil Saakashvili, the former president of that country.

Lord Ahmad of Wimbledon: My Lords, we are closely following events connected to the detention of former President Saakashvili. The former Minister for Europe, Wendy Morton, raised Mr Saakashvili’s detention with the Georgian Ambassador on 15 December, highlighting concerns about his health and treatment. Our ambassador and other officials have raised Mr Saakashvili’s case at senior levels in Tbilisi, including with the Deputy Foreign Minister and the Speaker of Georgia’s parliament. We will continue to monitor developments regarding this case.

Lord Harries of Pentregarth: I thank the Minister for his reply. Under Mr Saakashvili’s presidency, Georgia flourished economically. He took significant steps to eliminate corruption and when he lost power in 2013, he transferred power peacefully, the first ever peaceful transition of power in Georgia. Since then he has been stripped of his citizenship and put in prison on trumped-up charges in what Amnesty International describes as apparent political revenge. I pass all this on to the Minister, but my question focuses simply on his imprisonment. Yesterday I received a letter from him, smuggled out of prison, in which he talks about being denied private communication with his lawyers and being repeatedly assaulted by prison officials. Will Her Majesty’s Government protest most strongly to the Georgian Government about this and ask that our own ambassador might visit him in prison?

Lord Ahmad of Wimbledon: My Lords, I thank the noble and right reverend Lord for providing that additional information. I will of course take that forward and pass it to both our team here in London and our ambassador on the ground in Tbilisi. On the issue of Mr Saakashvili’s continued detention, we are urging the Georgian Government to ensure the fair treatment of the former president. We welcome recent steps to facilitate medical care for Mr Saakashvili and to accord him the right to due process in legal proceedings. I share the noble and right reverend Lord’s view of Mr Saakashvili’s tenure. Of course, when he returned in October he did so willingly and was at that time  taken into custody. I will certainly take forward, as the noble and right reverend Lord suggests, any further action on the additional information that he provides.

Lord Hannay of Chiswick: My Lords, while I recognise that it is not for this House or any Member of it to judge former President Saakashvili’s innocence or guilt, is the point being made to the Georgian Government that if, as I think we would much desire, there is to be an ever-closer relationship between this country and Georgia, it is going to count in that matter whether Georgia applies the provisions of the European Convention on Human Rights in full and in a correct manner?

Lord Ahmad of Wimbledon: My Lords, I agree with the noble Lord about the importance of the request by the European Court of Human Rights to the Government of Georgia that they ensure the safety of Mr Saakashvili and inform the court about the applicant’s current state of health. We will continue to make that case and, as I said earlier, to ensure that he is given both the right to legal representation and medical care.

Lord Collins of Highbury: My Lords, the former president’s detention is symptomatic of the greater problem of the deterioration of human rights in Georgia, particularly labour rights. According to the Georgian Trade Unions Confederation, just last year 22 workers died in one month alone. Can the Minister tell us, like he did yesterday, what he is doing to raise human rights and to work with the ILO to ensure that Georgia meets the obligations of that organisation, to which Georgia is also committed?

Lord Ahmad of Wimbledon: The noble Lord is quite right to draw attention to the issue of human rights and, if I could term it thus, the democratic backsliding that at times we have seen on rights generally across Georgia. I assure him that we are engaging directly. My right honourable friend the Foreign Secretary mentioned the importance of promoting democratic values, which is central to our foreign policy. On 1 December, during discussions with the Georgian Government in Tbilisi, our regional director for eastern Europe and central Asia raised important issues around various elements of human rights and, beyond that, the politicisation of appointments. There has also been a decline in LGBT rights; the noble Lord will be aware of the attack on the Pride march. All of this forms part of our engagement directly with Georgia.

Lord Purvis of Tweed: My Lords, I was in Tbilisi in 2017 shortly after the former president had his citizenship revoked while he was the governor of Odessa, in Ukraine. He subsequently also had his citizenship revoked by Ukraine. This situation is open to significant influence from Russia, in addition to the concern about the individual case. As the noble and right reverend Lord, Lord Harries, has indicated, Amnesty International has raised concerns that this treatment is political revenge. Will Britain indicate to the Georgian Government that operating under the premise of due judicial process and respecting human rights are core  elements of Georgia’s membership of the Council of Europe, and that working in this way is the best security against external influence from Russia?

Lord Ahmad of Wimbledon: I can certainly assure the noble Lord that that is exactly our approach. We will continue to raise this directly and with key partners, including in international fora such as the Council of Europe.

Lord Foulkes of Cumnock: My Lords, following on from that question, is the Minister aware that monitors from the Parliamentary Assembly of the Council of Europe visited Georgia last month? They have returned and said that is absolutely vital that the two main parties overcome the extremely polarised political climate. They are Georgian Dream and the United National Movement, which is Mikheil’s own party.
Will the Minister make particular use the Parliamentary Assembly of the Council of Europe and specifically ask our ambassador to the CoE to raise this issue at the Council of Ministers meeting, so that multilateral action can be taken? As I said during another Question earlier in the week, this kind of multilateral approach is much better than a government-to-government approach, which is sometimes misunderstood.

Lord Ahmad of Wimbledon: My Lords, I agree with the noble Lord and as I have said to him previously, I look forward to working with him directly on this agenda and I pay tribute to his valuable work within the Council of Europe. I am looking specifically at the work of the Council of Europe and will take forward what the noble Lord suggests. Whatever we do in the multilateral fora, as I said to the noble Lord, Lord Purvis, it is also important that we complement, consolidate and strengthen it through our bilateral representations.

Lord Campbell of Pittenweem: My Lords, in light of current events, would it be worth advising the current Administration of Georgia that admission to NATO requires a respect for human rights?

Lord Ahmad of Wimbledon: I assure the noble Lord that we remind Georgia in our bilateral discussions of its international obligations. Let us not forget that Georgia itself, in the breakaway republics of Abkhazia and South Ossetia, faces direct challenges of the very nature the noble Lord alludes to.

Ambulance Queues: Health Outcomes
 - Question

Lord Scriven: To ask Her Majesty’s Government what assessment they have made of the impact on health outcomes of the time spent by ambulances waiting in queues to transfer patients into hospital Accident and Emergency departments.

Lord Scriven: My Lords, I beg leave to ask the Question standing in my name and draw the House’s attention to my interests in the register.

Lord Kamall: We recognise that waiting times can impact outcomes, so patients in queues remain under constant clinical supervision and care and are prioritised according to need. Delays tend to be concentrated in a small number of hospitals, with 29 acute trusts across 35 sites responsible for 57% of the 60-minute handover delays nationally so far this winter. These trusts are receiving intensive support to improve, including through placement of hospital ambulance liaison officers and the safe cohorting of patients.

Lord Scriven: My Lords, half a million acute bed days each year are lost due to delays in discharge directly attributable to non-availability of social care, which leads to bottlenecks in emergency departments and ambulances being unable to unload patients. Does the Minister agree that the split of money raised by the health and social care levy over the next three years therefore needs to be more generous to social care, so people stop having to wait up to seven hours in the back of ambulances?

Lord Kamall: As the noble Lord will be aware, when the charge was initially announced it was intended to help with social care, which has been neglected for a number of years under successive Governments. Given the pressures of the backlog, the NHS has decided to divert some of those resources to help tackle it. We have invested money in social care in the short-term winter plan, and in the longer term we have announced extra investment to ensure that social care is an attractive career and offers real prospects.

Baroness Finlay of Llandaff: My Lords, does the Minister recognise that his response, saying that this involves a small number of trusts, does not address the data from NHS England for the seven days to January 2, which showed that 23% of all arrivals by ambulance had delays of half an hour or more—that is over 19,000—and that some 10% of patients waited more than an hour to be handed over? This meant that those ambulances were also unable to deliver first aid and first implementation of treatment to people who were waiting. Therefore, when patients arrived at emergency departments, they were even sicker than necessary, and it may be that some lives were lost.

Lord Kamall: The noble Baroness makes an important point. In anticipation of the winter crisis, last year we published the Urgent and Emergency Care Recovery 10 Point Action Plan to look at the direct pressures on not only A&E but the call centres, and at some of the wider system issues. For example, when people cannot get access to their doctor, they tend to go to A&E. At other times, they cannot get the replacement medication they want and have to call an ambulance to go to A&E and get it. We are looking at some of the wider system problems to make sure we address the backlog.

Baroness Thornton: My Lords, NHS workers on the front line have been warning for months and months that the service is under strain due to a combination of waning workforce, Covid, respiratory infections, a backlog of patients and a build-up of health problems over lockdowns. The Royal College of Emergency Medicine has been calling for months for a response from Ministers to provide short-term and long-term solutions. We called on the Health Secretary last summer for urgent additional support to be put in place. Why are we still waiting for that leadership and necessary support to materialise?

Lord Kamall: I am sure the noble Baroness will acknowledge that a number of people have been calling for ways to address this. The Government announced the Urgent and Emergency Care Recovery 10 Point Action Plan last year, which includes supporting 999 and 111 services, looking at primary care and community health services, greater use of urgent treatment centres, increased support for children and young people, better communications and call handling, improving inflow and hospital discharge, looking at mental health needs and a number of other issues. In each of those 10 points we have drilled down on working with trusts and the ambulance service to make sure we can address the issues that are currently being raised.

Lord Flight: My Lords, could the Government look at how many lives have been lost as a result of delays? I suggest this might be more of an issue than the Government are aware of.

Lord Kamall: We regularly talk to the NHS—every day, in fact. We have, for example, daily omicron calls. Looking at some of the data, over 925,000 calls to 999 were answered by the ambulance service in December 2021, which is nearly 30,000 calls a day. That is 2% more than in November 2021, 22% more than in November 2020 and 9% more than in December 2019. We have invested in more people in the call rooms, working with BT to better handle the calls, and ensuring we have more staff where we need them to handle the whole system and ensure we can respond quicker.

Baroness Evans of Bowes Park: My Lords, the noble Baroness, Lady Brinton, wishes to speak virtually. I think this is a convenient point for me to call her.

Baroness Brinton: My Lords, yesterday NHS England data showed that trolley waits of more than 12 hours in A&E rose in December to just under 11,000, which is three times higher than in December 2020. One hospital reported that it had a dozen patients waiting on a trolley for a bed for over 24 hours. The Minister has talked about extra money, but without staff and bed capacity in both hospitals and care homes, the crisis remains. Can he say what the Government are doing right now to help alleviate the current crisis?

Lord Kamall: I thank the noble Baroness for giving me the opportunity to say what the Government are doing right now. We are working closely with  ambulance services, NHS England and the Association of Ambulance Chief Executives to reduce the handover delays. The 10-point plan I referred to earlier goes into detail about how we handle this, both in handling calls at call centres—some calls are not emergencies, for example, and patients are directed elsewhere—and in making sure that the wider system is available to make sure that patients are unloaded within the 15-minute target and that ambulances are turned around as quickly as possible. Where we have spotted disproportionate pressures in the system, as in the 29 hospital trusts across 35 sites, we have focused more resources there.

Lord Forsyth of Drumlean: My Lords, I appreciate that my noble friend has to read out what he has in his brief, but would he take time to read the report on social care published by the Economic Affairs Committee of this House, which received pretty well universal endorsement? Will he then discuss with his colleagues whether we really have fixed social care and whether the resources he is claiming are sufficient to meet the problem?

Lord Kamall: I thank my noble friend for drawing my attention to the report and the work of that committee. I will commit to reading the report and look forward to future discussions with my noble friend and many noble Lords across the House.

Lord Bird: Would it be possible at this time to talk also about preventing the next crisis and the crisis after that? Are we not always chasing something? The NHS, which does not spend a large amount of money on prevention, is now being hoist by its own petard,

Lord Kamall: The noble Lord raises a very important point. One of the things the NHS is looking at in more detail, and something we will discuss in forthcoming debates on the Health and Social Care Bill, is how we move a system culturally to not only treat patients once they are ill or need treatment, and work in terms of prevention and encouraging healthier lifestyles. When patients are kept too long in hospital, they can lose certain facilities such as muscle function, so we need to look at prevention as opposed to just treatment. Getting the right balance is something that the NHS and the Department of Health and Social Care are looking at closely.

Baroness Jolly: My Lords, as a result of Covid’s impact, many A&E departments have reconfigured their internal infrastructure and their working practices. Could the Minister tell the House how best practice is being disseminated to other NHS trusts? What support, financial and otherwise, have trusts received to do this?

Lord Kamall: Given that it was identified that there were particular pressures on 29 trusts across 35 sites, extra resources have been targeted and teams have made site visits to work out, for example, the flows in those hospitals, and to make sure that they deal not only with the immediate issues that those departments face but also with the wider system issues. For example, as I have mentioned, sometimes patients  cannot get hold of doctors and go to A&E as a substitute because they want a face-to-face appointment. We are looking at a number of those wider issues. We announced £55 million of winter funding for all ambulance services and have boosted staff numbers by 700, including for the availability of the ambulance fleet, through a £4.2 million investment to improve times. We have also invested nearly £2 million to support the well-being of front-line staff during these pressures; they have experienced increased pressures, so we must make sure we look after them as well.

Lord Lea of Crondall: My Lords, is there a breakdown on the difference between physical resources in hospitals and the shortage of staff?

Lord Kamall: I am not sure whether there is a breakdown. As my noble friend said, sometimes I have to read out what is in the pack and sometimes I freelance, as I am sure many will appreciate—or maybe will not appreciate when I divert from the government line. But I will endeavour to find out whether those stats are available.

Money Laundering
 - Question

Lord Rooker: To ask Her Majesty’s Government what plans they have, if any, to commission an independent assessment of the scale of money laundering in the United Kingdom.

Lord Agnew of Oulton: My Lords, the UK money laundering regulations require the Government to make an assessment of the UK’s money laundering and terrorist financing risks and to keep this assessment up to date. The Government accordingly published a national risk assessment in 2015, 2017 and 2020. Assessments detailing specific threats are published by UK law enforcement more regularly, including by the National Crime Agency’s National Assessment Centre and the National Economic Crime Centre.

Lord Rooker: I thank the Minister for his Answer, but is he not curious about the effects of transnational kleptocracy by British professional service providers such as HSBC and Mishcon de Reya, which enable crooked elites to launder their money and reputations? Would he condemn, as does the recent Chatham House report, the lawyers and PR agents who make quasi-libel defamation cases against journalists and researchers researching money laundering and then go on to deter the ill-resourced regulators, who can be bought off, as in the recent Mishcon case?

Lord Agnew of Oulton: I am sure the noble Lord will be aware that a number of very substantial fines have been levied for breaching money laundering regulations over the last few years. In 2020, Goldman  Sachs was fined £48 million; in 2019, Standard Chartered was fined £102 million; and, even in the last few weeks, NatWest was handed a fine of £264 million. This just emphasises our commitment to dealing with this whole area.

Lord Kirkhope of Harrogate: My Lords, having had the dubious privilege of being one of those who helped to draft the anti-money laundering directives in Brussels, and thereby finding himself described by friends as an expert in money laundering, may I enquire about the word “proportional”, which appears in the directive? Does my noble friend feel that that word is being properly applied by our financial institutions to small investors and those who will never be engaged in money laundering? Does he think that that is balanced and fair and that we have the right approach?

Lord Agnew of Oulton: I would certainly defer to my noble friend as someone who is an expert in this area, which I am not. It is extremely difficult to get the right balance in these things, because what one person would consider an intrusion, another would consider a protection. We have to remain alert and sensitive to the different forces, but what is most important is that we have a coherent system which is clamping down on an extremely complex and fast-evolving crime.

Bishop of St Albans: My Lords, in last year’s parliamentary debate on the Church Action for Tax Justice report Tax for the Common Good, the Minister assured us that progress was being made on reducing money laundering and financial fraud in our British Overseas Territories and Crown dependencies. Would he be able to update the House on this? If he cannot do so now, would he please write to me with information on the progress we are making?

Lord Agnew of Oulton: It is important to remind the House that the overseas territories are independent entities and that we cannot just force them to comply with our own regulations. But we have an ongoing dialogue with them. For example, we have a very useful exchange of information through the exchange of notes arrangements, and they have agreed to introduce publicly accessible registers of companies’ beneficial ownership. The discussions are very much ongoing and I respect the right reverend Prelate’s concern.

Baroness Wheatcroft: My Lords, at the anti-corruption summit in 2016, the Government committed to producing a register of overseas owners of British properties. In 2018, they produced a draft Bill on that which has still to become law. Could the Government say whether they are in fact committed to stopping this sort of overseas activity in the UK?

Lord Agnew of Oulton: My Lords, I can assure the House that we are absolutely committed to stopping that. I accept that the introduction of the Bill is taking too long, but active discussions are going on at the moment about a new economic crime Bill and I hope that we might see its introduction within the next few months.

Lord Tunnicliffe: My Lords, the Minister’s colleague, the noble Viscount, Lord Younger, said during our proceedings on the NICs Bill:
“In the last three years, we have recovered over £550 million from the proceeds of crime, charged over 100 people with money-laundering offences, and seen over 75 people convicted for money laundering.”—[Official Report, 10/1/22; col. GC 113.]
That is a pathetic figure—or at least it feels like one. In his original Answer, the Minister indicated that assessments had been made over three recent years. What he failed to do was tell us what the answer was. Could he provide the answer so that we can judge the success so far and see whether the right resources and energy are being devoted to this issue?

Lord Agnew of Oulton: My Lords, if we were to go the very top-down figures, which are ultimately the most important, I would look at the tax gap, which we have been very successful in closing over a number of years. In 2005-06, the gap was 7.5%; in the last year for which figures were available, 2019-20, it was down to 5.3%. That is of course against the enormous headwinds of the build-up of hot money around the world. I would therefore be more optimistic and say that we are making good progress.

Baroness Evans of Bowes Park: My Lords, it is the turn of the Liberal Democrats. The noble Lord, Lord Jones of Cheltenham, wishes to speak virtually. I think this is a convenient point to call him.

Lord Jones of Cheltenham: My Lords, the Royal United Services Institute suggests that the scale of money laundering in the UK is “too big to measure”. Transparency International has had a stab at it and says that the problem may be causing £325 billion-worth of harm to the UK economy each year. Why has the UK become such a magnet for this illegal activity, which damages the vital financial services sector and our reputation as a safe place to do business?

Lord Agnew of Oulton: My Lords, as I am sure the noble Lord will be aware, the City of London is one of the largest financial centres in the world and therefore the flows of money going through our economy, particularly in the City, are enormous. However, we lead the world in our attempts to reduce bad activity. I refer the noble Lord to the Economic Crime Plan, which lists some 48 action points to tackle the whole spectrum of money laundering and financial crime. We are in good shape in implementing those, and we are committed to an economic crime plan 2.0 that will be announced this autumn.

Baroness Manzoor: My Lords, to take us back to the question on resources, there is some evidence that where banks refer cases to the police, such cases are not high on their agenda. Do the police have sufficient resources to tackle this crime and to investigate it thoroughly?

Lord Agnew of Oulton: My Lords, we have the National Crime Agency as the main crimefighting force in anti-money laundering. It is an extremely  effective organisation, and it is well funded. Of course, one could always say that more money is needed, but I can assure my noble friend that we believe that we have adequate resources.

Lord Anderson of Swansea: The Minister has mentioned some fines in respect of a limited number of banks, but much money laundering is in respect of property transactions, particularly in London. Since the passing of the Sanctions and Anti-Money Laundering Act 2018, how many prosecutions have there been of professional people who facilitate money laundering: the estate agents, the solicitors and others?

Lord Agnew of Oulton: My Lords, more than 97,000 organisations are monitored for money laundering in this country and some 54 anti-money laundering inquiries are open with the FCA at the moment.

Baroness Ritchie of Downpatrick: My Lords, the Minister has referred to the work of the Assets Recovery Agency. Paramilitary organisations have undertaken considerable money laundering over many years throughout the UK. Can the Minister provide us with a detailed assessment, including figures, of the amounts that have been laundered by paramilitary organisations? I am thinking in particular of Northern Ireland, where it has had an insidious impact on society.

Lord Agnew of Oulton: I share the noble Baroness’s concern about money laundering getting into the hands of serious organised crime groups, but we are very much aware of such concerns. I do not think that one can put a figure on it, because, if we knew what it was, we would be able to stop it. We have created a large umbrella structure to oversee all these organisations. It is overseen by the Chancellor and the Home Secretary. Underneath that sit a number of organisations; for example, the Office for Professional Body Anti-Money Laundering Supervision. A whole range of such agencies are now working and sharing intelligence. I believe that we are getting better all the time.

Railway Timetables: Disruption
 - Question

Baroness Randerson: To ask Her Majesty’s Government what steps they are taking to ensure that full railway timetables are restored as soon as possible, following the disruption caused by staff absences.

Baroness Vere of Norbiton: My Lords, the department has been working closely with rail operators to mitigate the impact of Covid-related staff absences on train services. Many operators have implemented temporary revised train timetables, which are providing passengers and especially the country’s  key workers with certainty so that they can plan their journeys with confidence. The department will continue to work with operators to ensure that services meet demand as staff absence pressures ease.

Baroness Randerson: My Lords, I regret that there was no absolute reassurance in that Answer that timetables would be restored. At the same time as reductions, the Government are requiring train operating companies to make 10% savings and imposing a 3.8% increase on fares for passengers. The Government found the money for freezing fuel duty and reducing domestic APD, but rail passengers face the double whammy of reduced services and higher prices. Does the Minister recognise that the Government should do everything they can to encourage us out of our cars and back on to public transport, but instead government policy is setting the railways up to fail?

Baroness Vere of Norbiton: I do not agree with the noble Baroness’s assessment that government policy is setting the railways up to fail. We are introducing all sorts of measures under the Williams-Shapps Plan for Rail which will improve rail services and make them fit for the future. It is the case that demand is currently running at around 55%; because of Covid absences, we have a temporary timetable in place—I reassure the noble Baroness that it is a temporary timetable, which she will know expires on 26 February. We are working closely with the rail industry in relation to the progress of omicron and how timetables may look in the future.

Lord Haselhurst: My Lords, is not the more potent factor in this situation the lack of passengers, which is making train operators wary of introducing services across the country that are visibly empty?

Baroness Vere of Norbiton: Not entirely, my Lords. Clearly, the rail operators working with the Department for Transport want to provide the services. At the moment, they cannot do so because of Covid pressures on staff, but we will work in the longer term with the rail industry to streamline the passenger offer, to remove duplication of services and to ensure efficiency.

Lord Adonis: My Lords, we are obviously in the middle of a public health crisis and the Government have difficult decisions to take, but will the Minister repudiate the prophets of doom who somehow think that we are all going to stop travelling in the usual way once Covid has ended? Will she acknowledge that in the periods when we have opened up between the waves of the pandemic, passengers have returned to the railways very quickly—passenger usage on the Tube in London was up to two-thirds before we had the latest lockdown—and that it would be a huge mistake if the Government were to start cutting services, which would discourage people from returning to the railways after 20 years of massive investment in them, which has been a great good news story for this country?

Baroness Vere of Norbiton: The Government are very keen for passengers to return to the railways. We are working closely with the industry as it supports demand and revenue recovery. However, we accept that there may be enduring changes in the way in which people travel, whether it be for work versus leisure. That is why the Rail Delivery Group is working closely with VisitBritain to establish a new domestic rail tourism product, so that we might perhaps go interrailing around our own nation.

Lord Berkeley: My Lords, the noble Baroness, Lady Randerson, mentioned the 10% cut that the Treasury has asked all the rail industry to impose. Can the Minister confirm that the Night Riviera sleeper, which keeps Cornwall connected to London and the rest of the country, is safe from this, or will that be cut as part of the 10%?

Baroness Vere of Norbiton: My Lords, I cannot comment on the Night Riviera sleeper; I wish I could, but I will write if I can find out any information on it. However, we do need to look at our railways to ensure that they are financially sustainable for the future. The Government have committed £14 billion since the start of the pandemic to support our rail sector. We know that in future, we will be looking for workforce reforms and cost efficiencies. We want passengers to come back and, of course, overall, we want an excellent performance for all passengers and freight.

Baroness Fox of Buckley: My Lords, the less than full railway timetables are not solely caused by Covid-related staff shortages. The hourly Chester to London and London to Chester direct trains have just disappeared. Whenever I make any queries about the return to the pre-lockdown timetable, I am met with an “It’s Covid, innit?” shrug. Can the Minister look at this cavalier establishment of the new normal as a cover for what are, effectively, cuts in services? Worryingly, it is not just confined to the rail network, but it is always at the expense of the public and it is happening without anyone discussing it.

Baroness Vere of Norbiton: I am not sure I agree with the noble Baroness. Clearly, we are discussing it today and we have discussed timetables in the past. Timetables are never static: they have changed twice a year for a very long time. It is true that we will be asking the rail industry to submit plans through the routine business-planning process, and it may well be that there are further changes to timetables. We do, however, ask all the rail operators to engage very closely with local communities to ensure that we are able to deliver the right services to the right places.

Lord Tunnicliffe: My Lords, the Government recently announced that 100,000 tests would be made available for key workers, but the Minister will be aware that the number of key workers available is many millions. Can she confirm how much of the 100,000-testing commitment will be designated for public transport, and what proportion of the workforce she expects that to cover?

Baroness Vere of Norbiton: I do not have the figures with me today, but I can say that those 100,000 tests were actually for critical workers rather than key workers. These people are even more critical than key workers. The sort of places we will be using those tests for are places such as operation centres: you literally cannot replace one person for another when it comes to rail service operators. We are looking at those people without whom we cannot do. That is really important, because they are critical—more critical than some other workers.

A noble Lord: They cannot get to work.

Lord Cormack: My Lords, can the Minister say—she did not really answer the noble Baroness, Lady Randerson, fully on this—when we can expect to have a reasonably certain timetable? Those who travel by train regularly need to be able to plan carefully, and many of us feel that, although Covid has been a reason for much, it has been an excuse for many things as well.

Baroness Vere of Norbiton: I completely accept my noble friend’s point. It is the case that we want all passengers to be able to travel with confidence. At the moment, we are advising passengers to check first, but that is why the process that we put in place because of the Omicron intervention was two-phased. There was a reactive phase over Christmas, which necessitated some short-term cancellations. We knew that employee absences would possibly rise, so that is why we were proactive and put in place this planned timetable just for six to eight weeks until 26 February. That will provide some certainty until then. Then, of course, I would have to ask my noble friend to look at the timetable again.

Baroness Pinnock: Earlier, the Minister said that the Government were very keen for passengers to return to the use of rail. What would she say to rail travellers in Yorkshire, who are facing the insult of increases in rail fares totalling nearly 50% over the last 10 years or so, yet are also facing services in relative decline? There will be no HS2, no HS3 and no full electrification. Yorkshire folk like value for money and they are not getting it. What does the Minister have to say to them?

Baroness Vere of Norbiton: I just point the noble Baroness to the Williams-Shapps plan for rail. There is an enormous amount in there that will be beneficial to passengers in Yorkshire and beyond. We will be looking at ticketing, which is insanely complicated. Sometimes multi-leg ticketing is cheaper than a single leg and it is all slightly mad. Obviously, we will be very passenger-focused to make sure that the right services exist for people in Yorkshire and beyond.

Baroness McIntosh of Pickering: My Lords, can the Minister confirm that those drivers of trains on shunter routes are paid less than those on, for example, the east coast main line route and the west coast main line route? Is there any evidence of an exodus of these drivers to earn higher salaries as lorry drivers?

Baroness Vere of Norbiton: I am not sure that the skills are interchangeable, but it could be that some people have chosen to become HGV drivers instead. However, I reiterate that the rail services that we currently have are not financially sustainable without workforce reforms. That is going to be an absolutely essential part of the way we take forward rail services in this country. We need to make sure that we have the right people on the right trains on the right pay and with the right conditions.

Commonwealth Parliamentary Association (Status) Bill [HL]
 - First Reading

Baroness D'Souza: My Lords, I declare my interest as an executive committee member of CPA UK.
A Bill to provide for corporate status of and for certain privileges and immunities to be accorded to the international inter-parliamentary organisation of national and sub-national legislatures of Commonwealth countries known as the Commonwealth Parliamentary Association and to its Secretary-General; and for connected purposes.
The Bill was introduced by Baroness D’Souza, read a first time and ordered to be printed.

Lead Ammunition (Restriction) Bill [HL]
 - First Reading

A Bill to restrict the possession, use and sale of lead ammunition; and for connected purposes.
The Bill was introduced by Lord Browne of Ladyton, read a first time and ordered to be printed.

Commercial Rent (Coronavirus) Bill
 - First Reading

The Bill was brought from the Commons, read a first time and ordered to be printed.

Vaccination Strategy
 - Commons Urgent Question

The following Answer to an Urgent Question was given in the House of Commons on Wednesday 12 January.
“We have built three lines of defence to give us the best chance of living with Covid-19 and avoiding strict measures: vaccination, testing and treatments. Vaccination is the most important of those three, especially in light of the new omicron variant. Recent data from the UK Health Security Agency shows that unvaccinated people are between three and eight times more likely to be hospitalised with Covid-19, so every jab counts in keeping people out of hospital and saving lives.
Since omicron began making its way around the world, our strategy has been to massively expand vaccination. We set the highly ambitious target of  ensuring that everyone eligible for a booster would be offered one by the end of December, and we met that target. Some 80% of eligible adults in England have now had the booster, including 87% of people over 50. That means that, per capita, we are the most boosted large nation on the planet. In addition, more than 1.4 million young people aged 12 to 15 have already had their first dose since the vaccine was rolled out to that age group in September, with thousands still getting jabbed every day. As of 10 January, eligible children aged 12 to 15 are being offered a second dose in their school. The vaccination effort is a vital part of ensuring the safe return of pupils to the classroom after Christmas, and the continuity of in-person education, which we know is so important for their development.
Throughout our vaccine programme, we listened to the advice of the Joint Committee on Vaccination and Immunisation, whose clinical expertise is second to none. As we have done so, our vaccination strategy has been highly successful, allowing us to live with fewer restrictions than many other places around the world and keeping our children in education settings, where they belong. Once again, I underline my thanks to everyone who has made our national vaccination programme possible, including the JCVI, the NHS, our vaccines taskforce, the vaccinators and all volunteers across the country. I am sure that the whole House will join me in thanking them for everything that they have achieved.”

Baroness Merron: My Lords, I pay tribute to the staff of the NHS, volunteers and others, who have made extraordinary efforts during the vaccine rollout to save lives and build a world beyond Covid, while a particular debt of gratitude is owed to the Deputy Chief Medical Officer, Jonathan Van-Tam, who is standing down from his role.
To drive up vaccination rates, there is a growing need to tackle anti-vax propaganda and stop intimidation and abuse. Will the Minister commit to a communications campaign to tackle misinformation, particularly focusing on places and people with lower rates of take-up? Following the Labour amendment to the policing Bill that was agreed last night in your Lordships’ House, will the Government now take the opportunity to fast-track buffer zones around schools and vaccination centres?

Lord Kamall: I thank the noble Baroness for raising these issues. The first issue, that of anti-vaxxers, is really important. In a free society we always have to get the balance right between freedom of speech, making sure that people are free to go about their daily work, and making sure that those who want the vaccine get it as soon as possible. The Government are aware of this and are looking at it, but it is really important that we get the right balance. Whatever we think of the anti-vaxxers’ message, they have a right to say it, but we have to make sure that it does not impinge on the liberty of others to get their vaccine, especially since we are encouraging as many people as possible to get vaccinated.
I join the noble Baroness in paying tribute to the Chief Medical Officer, Jonathan Van-Tam. He appears on our daily omicron calls and I have had a number of conversations with him, and I know that there is incredible respect for JVT across the country. Indeed, I know that a number of people tuned in to his Christmas lectures on the virus; as the noble Baroness says, they were an excellent explanation of the virus and how to tackle it.
As for how we reach local communities, particularly those communities that have not come forward, I have had a number of conversations with noble Lords and Baronesses with their own experience of working with local communities in a bottom-up way. We have seen a number of local activities; indeed, my local masjid, or mosque, has a walk-in vaccination centre, and we have seen that in other faith places. A number of faith-based and interfaith networks have worked closely with the local community, because often some communities do not have the trust in authority that they have in priests, vicars, bishops—if I may say so—imams, et cetera. That is really important. We have also recorded promotional films in a number of languages, including Punjabi and Urdu in Birmingham, and got some celebrities to come up. I know I have gone on too long but I am very excited about what we are doing.

Lord McFall of Alcluith: The noble Baroness, Lady Brinton, is taking part remotely. I invite the noble Baroness to speak.

Baroness Brinton: My Lords, I too echo the gratitude that this House and this country shows to Jonathan Van-Tam. Four months on, there are still severely clinically extremely vulnerable people eligible for a third primary dose and then a booster who cannot book their booster because the data system still cannot record this. Many CEV young children with underlying conditions are still waiting for their vaccines, as well as for guidance on how they, their families and their schools can keep them safe from Covid. This is important because there are now more children in hospital with Covid in the last three weeks than in the nine months of the first wave. Please can the Minister say how these people, who the Government say need the vaccines right now to keep them safe, can get them?

Lord Kamall: I thank the noble Baroness for making me aware of the issues. She will recall that we had a meeting on how we can address the concerns of the clinically extremely vulnerable, and I had hoped that a number of action points had flowed from that. If those have not been acted upon, I hope she will write to me and I can chase up the department and the NHS. I had assumed that that meeting, where we gave them some action points, was effective. I am sure she remembers that we requested a letter with action points, but if those have not been followed up, I will endeavour to chase that up.

Lord McFall of Alcluith: The noble Baroness, Lady Masham of Ilton, is taking part remotely. I invite the noble Baroness to speak.

Baroness Masham of Ilton: My Lords, how much research is being done on persons who may have developed Guillain Barré syndrome after the coronavirus vaccine booster? Is the noble Lord aware that there have been several cases of this serious condition recently?

Lord Kamall: I thank the noble Baroness for the question. I will have to write to her with the answer.

Bishop of Gloucester: Can the Minister update us on global statistics on vaccination? This is not only about justice, equality and dignity; it is also about the fact that new variants will arise unless we address the issue of international vaccination. What are the Government doing to ensure that everyone across our world is offered full vaccination? What focus is being given to the international situation, beyond ourselves?

Lord Kamall: I thank the right reverend Prelate for raising this incredibly important issue. I know a number of noble Lords across the House feel very strongly about this. Indeed, many of us are part of diaspora communities and understand that many communities across the world are very concerned. From the start of the pandemic, the UK has worked to support access to Covid-19 vaccines. We helped to establish the international joint procurement initiative, COVAX. At the end of 2021, the Government confirmed that they had delivered more than 30 million Covid-19 vaccines to other countries, benefiting more than 30 countries. We have invested £71 million to help COVAX secure early supply deals. The UK is one of the largest donors to the COVAX advance market commitment, which supports access to Covid-19 vaccines for up to 92 low and middle-income countries. I have a list of a number of other initiatives that we have taken part in. In addition, in bilateral, G7 and G10 discussions, we have put this issue on the agenda, making sure that we are working in a multilateral way across the world to help those countries.

Lord Patel: My Lords, first, in relation to the question asked by the noble Baroness, Lady Masham, very few cases of Guillain Barré syndrome have been reported following vaccination with Covid vaccines. That is not so surprising because it occurs with any vaccination, so it is not a reason at all for anybody to be denied vaccination. Secondly, and much more importantly, social media is full of worries that young women are particularly affected, because of the nonsense perpetrated that it will make them infertile. There is no scientific reason behind this. Does the Minister agree that all young women should take the vaccine? Thirdly, there are many pregnant women now in hospital because they were not vaccinated because of wrong advice that pregnant women should not be vaccinated. Again, there is no reason why pregnant women should not be vaccinated, and the recent data which suggests that mothers who breastfeed will transfer their antibodies to the newborn is good news too.

Lord Kamall: One of the wonderful things about your Lordships’ House is its range of expertise. I thank the noble Lord for enlightening us on the  earlier question. However, as I committed to the noble Baroness, I will check the department’s reply and hope it corresponds with the noble Lord’s response; otherwise, I am sure we will have more discussions.
On young women, the noble Lord is absolutely right that we should be encouraging as many people as possible to take the vaccine, even—I know this is being broadcast publicly—those who have not had their first or second vaccine. It is not too late. We urge everyone to have their first and second vaccine, but also to have the booster. It is the best protection, even for those who have previously had Covid. We know that almost all pregnant women who are hospitalised or admitted to intensive care with Covid-19 are unvaccinated. The latest data from the UK Health Security Agency shows that Covid-19 vaccinations provide strong protection for pregnant women against the virus. It shows that the vaccines are safe for pregnant women, with similar birth outcomes for those who have had the vaccine and those who have not. We have launched a new campaign that urges pregnant women not to wait to take the vaccine; it highlights the risks of Covid-19 to mother and baby and the benefits of vaccination.

Baroness Blackstone: My Lords, I declare my interests as set out in the register. Following on from the question of the noble Lord, Lord Patel, I want to pick up the issue of pregnant women. The Government have belatedly—very belatedly—announced a campaign to persuade pregnant women to get vaccinated. Had they done it earlier, some deaths would have been avoided. Is the Minister aware of the particularly low levels of vaccination among pregnant women from ethnic minorities? What are the Government doing to reach out to them in particular, to persuade them to get vaccinated and save their own lives and those of their unborn children?

Lord Kamall: The noble Baroness makes an incredibly important point that I am sure we all agree with. This is a combination of two issues. One is reaching those communities that generally, pregnant or otherwise, are not being vaccinated. The other is making sure that pregnant women are receiving the message that it is safe to have the vaccine. We are doing this through a number of channels, including through medical staff and the NHS, but we also have a number of targeted campaigns, looking at those communities to make sure we build trust, break those gaps down and give them the confidence to come forward and be vaccinated.

Afghanistan: Humanitarian Crisis
 - Commons Urgent Question

The following Answer to an Urgent Question was given in the House of Commons on Wednesday 12 January.
“Afghanistan is facing a serious and worsening humanitarian crisis. It is affecting well over half the population, with 23 million people facing acute food insecurity. This is now the world’s most severe food security crisis. The UN has this week requested nearly $4.5 billion for 2022—the largest humanitarian appeal on record, reflecting the magnitude of the humanitarian challenge ahead.
The UK has been at the forefront of efforts to address the situation, working with the UN Security Council, the G20, the G7 and countries in the region. The Prime Minister, the Foreign Secretary and other Ministers have all been working extensively with world leaders. In August, the Prime Minister announced that the UK would double its assistance for Afghanistan to £286 million this financial year, and we have now disbursed over £145 million. That will support over 3.4 million people in Afghanistan and the region, providing emergency food, healthcare, shelter, water and protection. We are working at pace to allocate the remaining funding in response to the developing crisis and the new UN appeal. Further details were in the ministerial Statement on 15 December. I thank the British people for donating £28 million to the Disasters Emergency Committee appeal in December, of which £10 million was doubled by UK aid match funding. That has helped to provide lifesaving support.
We were particularly concerned about the impact of the situation on women, girls and other marginalised groups. Last month I, alongside the Minister of State with responsibility for South Asia, Lord Ahmad, met organisations representing women, LGBT+ and religious minorities to discuss support for their needs. In allocating UK aid, we want to ensure that women, girls and other marginalised groups have equal, safe and dignified access to assistance and services. We have pressed the Taliban to respect humanitarian principles.
Our partners report that aid is getting through. We continue to monitor the situation very carefully, especially in the winter months. Aid workers face challenges getting money into Afghanistan due to the banking system. We are working closely with multilateral organisations, banks and non-governmental organisations to address those challenges. We welcome the decision by the World Bank board in November to transfer £280 million to support the humanitarian response, but it is vital—it is vital—that the World Bank produces options to allocate the $1.2 billion remaining in the fund. It is important that donors across the world step up to the challenge, including by responding to the UN’s call for additional funding.”

Lord Collins of Highbury: My Lords, I recognise that the Answer acknowledges the efforts of the United Kingdom to mobilise the international community on this terrible situation that has developed, but can I ask a specific question? Gordon Brown wrote to the Foreign Secretary specifically to ask that Britain convenes an international pledging conference, certainly no later than February—he stressed perhaps earlier, in January—to raise the necessary £4.44 billion to ensure that the 23 million people suffering are fed in the year 2022. Secondly, did the Minister hear on Radio 4 this morning the interview on British Council employees who have been left stranded in Afghanistan? What can he tell us? Can he give us some assurance that assistance will be given to them?

Lord Ahmad of Wimbledon: My Lords, first, I thank the noble Lord for acknowledging  the work that the UK Government are doing with international partners in what is, as the noble Lord rightly described it, a terrible and continuing perilous situation on the humanitarian front in Afghanistan. I assure the noble Lord that we remain fully committed. As he will be aware, I laid a Written Ministerial Statement in advance of Christmas detailing the agencies we are working with and the amounts we are giving in support, particularly targeting vulnerable groups. We will make additional announcements, particularly in light of the call to action and the new request from the United Nations.
I share with the noble Lord that the previous request was made for flash funding support for the UN. It is quite noticeable was that it was fully funded; indeed, funds are being distributed. He make a point about Gordon Brown calling for a meeting to be convened. We are, of course, working very closely with the United Nations in this respect. Any calls to action are welcome, and we will see how best we can mobilise further action. I will be speaking with key partners in the region to ensure that the call that has been made is also funded in the manner that is currently required.
On the British Council, I first pay tribute to the noble Baroness, Lady Smith of Newnham, who has been meticulous and consistent in raising in particular the issues of the British Council, along with other noble Lords. Let me give the noble Lord this reassurance: with the opening of the ACR scheme now formally announced, the promised support to cohorts, including the Chevening scholars and the workers associated with the British Council, will be upheld.

Baroness Barker: My Lords, the noble Baroness, Lady Harris of Richmond, is taking part remotely, and I invite her to speak.

Baroness Harris of Richmond: My Lords, what are the Government doing to secure safe passage of food and essential supplies to the most vulnerable in Afghanistan?

Lord Ahmad of Wimbledon: My Lords, I am working directly and very closely with key agencies on the ground in this respect. Just before Christmas, I had a number of meetings, including with the likes of David Beasley of the World Food Programme. I assure the noble Baroness that through direct interaction, including with near neighbours, we have access points which are providing humanitarian support to all regions of Afghanistan. Indeed, I was updated on that just this morning. I will continue to update the House, as I have done, through briefings directly at the Foreign Office as well as through debates and discussions we have in your Lordships’ House.

Baroness D'Souza: My Lords, could the Minister say what discussions, if any, are being held or planned with the authorities in Kabul and at provincial level to assist in the distribution of humanitarian aid? I imagine that the Taliban will be there for the next few months at least, if not more, and presumably discussions will take place. Some agreement has to take place, and I wonder what the attitude of the British Government is under these circumstances.

Lord Ahmad of Wimbledon: As the noble Baroness will be aware, we have taken direct action in the sense of having officials who have visited Kabul continuing to engage at official level on these very priorities that she listed: humanitarian support and aid distribution within Afghanistan. Earlier this morning, I met Sir Simon Gass, who is one special representative among others. We are also looking forward to others engaging directly with the Taliban operationally. On the specifics, I assure the noble Baroness that we are working with the United Nations High Commissioner for Refugees, the UN commission directly on the ground, as well as UNICEF, the World Food Programme and the ICRC, all of which have operational agreements and arrangements in each state to ensure effective distribution. There are others such as the Aga Khan Development Network, which has assured me through direct meetings that all its facilities—including support for the population, such as health clinics—are fully operational.

Lord Howell of Guildford: My Lords, is this not a situation where we are going to have to work closely and carefully with the Chinese? They seem to be acceptable to the Taliban and are working closely with them. The Chinese are always talking about the win-win nature of their intervention, which I think we have to take with a pinch of salt, but there is no doubt that they have the resources. They are there and they have substantial volumes of aid ready to bring in, and we have the humanitarian skills. Maybe this is an area where, despite all our very extensive differences with them in other areas, we might have to work together to get results.

Lord Ahmad of Wimbledon: My Lords, there are often challenges to the multilateral agencies working on the ground, particularly the United Nations. It is crises such as the Afghanistan crisis which really show the best of the world and how we can come together in response to humanitarian crisis. The UN provides the umbrella whereby we can work with all international partners, including China as well as others, to ensure humanitarian aid reaches those who most need it.

Baroness Northover: Taken together, given the expertise in the FCDO in relation to Afghanistan—even with cuts in funds—will the department play a key role in the MoJ/Home Office decisions made under the Afghan citizens resettlement scheme on who will be admitted to the United Kingdom because their lives are in danger in the country? The situation since August has been totally unacceptable.

Lord Ahmad of Wimbledon: My Lords, since August we have helped close to 4,000 people to leave Afghanistan. The noble Baroness rightly raises the issue of co-ordination. The recent announcement by the Minister for Afghan Resettlement outlined the various schemes and the pathways within each scheme. I have already alluded to one pathway where the Foreign, Commonwealth and Development Office is directly involved with the commitments we have made. I assure the noble Baroness that, overall, both with the department concerned, which is the MoJ, where Victoria Atkins sits, and more broadly—with the ARAP scheme, for example, which continues to be administered and run by the Ministry of Defence—we continue to co-ordinate and work together.

Lord Grocott: My Lords, we know that before the full takeover by the Taliban, there were many examples of co-operation between the Taliban locally and aid organisations, though it was very patchy in different parts of the country. Can the Minister tell us anything about the direction of travel on this post the Taliban takeover? Is it still patchy, or is there any evidence at all that those areas where the co-operation did not work successfully are learning from those where it does and benefits the people? How is this moving? Is it getting better or worse?

Lord Ahmad of Wimbledon: My Lords, as the noble Lord will be aware, there are various strands. The Taliban themselves are not a homogenous group, and there are various factions within the Taliban which control various parts of the country. However, promisingly, I was updated that with the commitments we have made and the support we have given to organisations, such as the World Food Programme, they have been able to distribute humanitarian aid and support not just to a selective number of regions but to most parts of the country. We are encouraged that there is good co-operation on the ground, but this could change very quickly, so we should we remain ever vigilant. I assure the noble Lord that I will continue to update your Lordships’ House accordingly.

Baroness Sugg: My Lords, the Answer acknowledges the impact on women and girls, and we have seen brave women protesting in the streets across Afghanistan. Can the Minister tell me if any women have been part of the UK delegations meeting the Taliban, and does he agree that such representation sends an important message of support to women in Afghanistan?

Lord Ahmad of Wimbledon: My Lords, the answer to my noble friend’s first question is positive: it is “yes”. We are engaging directly through our diplomats. Secondly, I have certainly been encouraging other key partners, for example Qatari Minister Al Thani and Amina Mohammed, the Deputy Secretary-General of the United Nations. Women are an integral and leading part of the world community. If the Taliban want to engage, it is important that we also fully support women’s full engagement. Equally, I can share with my noble friend that some leading lights of the former Afghan Government are right here in the United Kingdom. Earlier this week, I met with the brave, courageous Fawzia Koofi, and we are working directly with Afghan women who were part of the Administration, such as Hasina Safi, the former Minister for Women, to ensure that our next steps and future policies are informed by those who know best, who are the women of Afghanistan.

Health and Care Bill
 - Committee (2nd Day)

Relevant documents: 15th and 16th Reports from the Delegated Powers Committee, 9th Report from the Constitution Committee

  
Clause 3: NHS England mandate: general

Amendment 11

Baroness Thornton: Moved by Baroness Thornton
11: Clause 3, page 2, line 20, at end insert—“(3A) In section 13G (duty as to reducing inequalities), at end insert—“(2) NHS England must publish guidance about the collection, analysis, reporting and publication of performance data by relevant NHS bodies with respect to factors or indicators relevant to health inequalities.(3) Relevant NHS bodies must have regard to guidance published by NHS England under this section.(4) In this section “relevant NHS bodies” means—(a) NHS England,(b) integrated care boards,(c) integrated care partnerships established under section 116ZA of the Local Government and Public Involvement in Health Act 2007,(d) NHS trusts established under section 25, and(e) NHS foundation trusts.””Member’s explanatory statementThis amendment would give NHS England a statutory duty to publish guidance on how NHS bodies should collect, analyse, report and publish performance data on factors and/or indicators related to health inequalities.

Baroness Thornton: My Lords, it is a privilege to open this debate on the issue of health inequalities. I am grateful to all noble Lords who have gone through the Bill to ensure that addressing health inequalities is absolutely central. Unless the Bill deals with the kind of inequalities that the pandemic, for example, has brought into sharp relief, it will have failed. Many amendments in this group directly and indirectly address the issue, and I look forward to the many contributions we will hear. This is one area where our NHS may not be among the best in the world. In fact, inequality is often entrenched. Some might argue that, through the famous inverse care law, it even makes things worse. As with other public services, the better-off, with better connections and sharper elbows, get more out of a service than those with less social capital who are already disadvantaged by other factors.
A report published today by the Northern Health Science Alliance, a health and life sciences partnership between the leading NHS trusts, universities and academic health science networks in northern England, says that
“people in ‘left behind’ neighbourhoods are 46 per cent more likely to have died from the virus than those in the rest of England, and 7 per cent more likely to have died of the virus than those living in other deprived areas”
that are not left behind. In left-behind neighbourhoods,
“Men live 3.7 years fewer and women 3 years fewer than the national average,”
and
“men and women can expect to live 7.5 fewer years in good health than their counterparts in the rest of England.”
Tackling the health inequalities facing local authorities of left-behind neighbourhoods and bringing them up to England’s average could add an extra £29.8 billion  to the country’s economy each year. The co-chair of the All-Party Parliamentary Group for “Left Behind” Neighbourhoods, the right honourable Dame Diana Johnson, said that:
“Every person in the country deserves to live a long life in good health”,
but this new research demonstrates that this is not currently a reality.
We are all aware of the work of Sir Michael Marmot. In his review, which explored the changes since 2010, he highlighted five policy areas:
“—Give every child the best start in life —Enable all children, young people and adults to maximise their capabilities and have control over their lives —Create fair employment and good work for all —Ensure a healthy standard of living for all —Create and develop healthy and sustainable places and communities”.
The key messages from that review make stark reading. This is one of the strongest:
“The amount of time people spend in poor health has increased across England since 2010. As we reported in 2010, inequalities in poor health harm individuals, families, communities and are expensive to the public purse. They are also unnecessary and can be reduced with the right policies.”
In a note that I think all noble Lords will have received from Crisis and other voluntary organisations, they point out that, as it stands, people who experience the most extreme health inequalities, such as those who are homeless, sex workers, Gypsy, Roma, Travellers, vulnerable non-UK nationals and people with substance misuse issues, encounter significant barriers to accessing and receiving the healthcare that meets their needs. These barriers can include stigma, the lack of a fixed address or ID, fragmented services, the lack of continuity of care because of unstable accommodation, and lack of awareness from healthcare professionals of specific needs.
These can be reduced by the right policies and the right action. Health inequalities are not inevitable. Evidence shows that a concerted approach, implemented through the NHS and wider policies to address socioeconomic causes of poor health, can make a difference. The most recent national cross-government health inequality strategy was successful in narrowing the life expectancy gap between the most and least deprived communities. But I am afraid it was scrapped in 2010, and since then inequalities have widened as improvements in life expectancy have slowed.
The Bill offers a potential route to strengthen action on health inequalities, and there are three ways to improve the Bill: first, strengthening the existing core of inequalities duties; secondly, boosting the triple aim; and thirdly, ICS structures facilitating greater action on health inequalities. This suite of amendments addresses most of those.
Without doubt, healthcare should have the strongest role in tackling inequality and, in that, the strongest role should be played by public health. It is the part that has not been lucky enough to receive at least some protection from austerity, as the NHS did. Some of the unintended but inevitable consequences of the failure to invest in public health have been seen in the pandemic. Cuts have their consequences, and we have all been suffering them.
We cannot avoid, in a debate about inequalities, reference to the report An Avoidable Crisis, an investigation by my noble friend Lady Lawrence into why black, Asian and minority-ethnic communities were dying at a disproportionate rate during the pandemic. It was immediately apparent that the impact on people’s health was inseparable from economic prospects and experiences of discrimination. She says:
“It will require systemic solutions to systemic problems. It is not enough for policymakers to know that ethnic inequalities exist. We need to honestly confront how inequalities at all levels of society have come to exist and the intersectional impact it has on each ethnic group. This means recognising the interaction of faith, class, gender, disability, sexuality, ethnicity and culture in order to truly understand that no community is ever one homogeneous group.
Only then will we be able to respond effectively. We need bold, joined-up policies and an approach that encompasses tackling ethnic disparities, from housing to employment and health.”
Reducing health inequalities is not an ideological or moral standpoint; it is now well accepted that an unhealthy population is less productive, and there is a loss of economic efficiency and we all lose. The Bill offers us an opportunity to start to remedy that situation.
Those who have been lucky enough to go through the proceedings of the Bill Committee in the Commons will have seen that the Government accept the need to focus on reducing inequalities but claim that this is already a requirement expressed elsewhere in legislation. Because at present this is largely an NHS Bill, many amendments seek to make it a comprehensive health and care Bill. Only when mental health, public health, primary care and community care are all working in collaboration will we actually tackle health inequalities. I beg to move.

Baroness Barker: My Lords, the noble Lord, Lord Howarth of Newport, is taking part remotely in these proceedings and I now call him to speak.

Lord Howarth of Newport: My Lords, Professor Sir Michael Marmot’s work, to which my noble friend just alluded, has shown that health inequalities have widened across England in the last 10 years. The impact of these inequalities has been both exemplified and amplified by Covid-19. I support Amendments 11, 14 and others that address this massively important problem and I fully agree with my noble friend’s analysis.
Health is powerfully influenced by the social, economic and environmental conditions in which people live and work. Place-based and whole systems are therefore vital to improving health and reducing inequalities. This is recognised in the NHS Long Term Plan and the move towards integrated care.
Sir Michael endorsed the findings of the Creative Health report of the All-Party Parliamentary Group on Arts, Health and Well-being, which in 2017 documented over 100 studies on how the arts and creative activities have supported health. In 2019, the World Health Organization’s scoping review of the role of the arts in improving health and well-being provided evidence that creative activities could mitigate the detrimental impact of stressful environments and the negative health impacts of growing up in disadvantaged  conditions. Engaging with the arts, the evidence shows, can improve social cohesion and lead to a reduction in social inequalities in deprived areas. It can build skills and mutual support, which can improve social mobility. The positive effects of the arts can make a particular impact on early years development, as is demonstrated in the evidence provided to DCMS by Dr Daisy Fancourt et al in 2020.
Social prescribing, through bringing people together in shared creative activity and voluntary work, helps to build social capital and better health and well-being in deprived communities.
Research by the MARCH network, a UKRI-funded research programme, has shown that the health benefits of engaging with cultural and other community activities are felt by all, regardless of socioeconomic status. We know that there is a social gradient in participation in cultural and community activities and that those living in areas of higher deprivation are less likely to engage in them. However, the MARCH research indicates that when individuals in areas of high deprivation do engage, the mental health and well-being benefits may be particularly great for them, even greater than for those who live in more affluent areas. Therefore, targeted investment in cultural and community opportunities in areas where people are likely to benefit most can help to reduce health inequalities.
For instance, in Manchester, the Natural Cultural Health Service of the Whitworth art gallery is encouraging activities by local residents from diverse backgrounds that promote physical and mental well-being. Contact, a theatre company, supported by the Wellcome Trust, offers a health and well-being space for use by local community groups. Manchester Camerata has moved its base to Pugin’s wonderful Gorton abbey, in a deprived part of the city. Its musicians are working to support people with dementia and the Camerata is providing a resident composer and musician for local schools. Evaluation has shown that encouraging children to express themselves through music-making has raised their confidence and self-esteem, with a positive impact on their schoolwork and all the implications for them and their community that can follow from that.
The Big Noise project, run by Sistema Scotland in Govanhill since 2008, provides free orchestral training to young people. Evaluation has shown positive health outcomes as a result of improved confidence, social and other skills and emotional well-being. Similarly, the Royal Liverpool Philharmonic has run its In Harmony project to improve the life chances of children through music, and since 2009 has benefited 2,500 children in the Everton and Anfield areas of Liverpool.
The cultural and VCSE sectors have a key role to play in reducing health inequalities and should be fully embedded at systems level and in the health decision-making process. Integrated care partnerships provide the gateway to making this happen.
The National Centre for Creative Health, a charity of which I am chair, is currently working in partnership with NHS England in pilot programmes with four ICSs with a specific focus on mitigating health inequalities. We are looking to establish how best to embed creative health into healthcare strategies. We are also hosting a further AHRC-funded research project called Mobilising  Cultural and Natural Assets to Combat Health Inequalities. The outputs will support ICSs to maximise the potential of the arts and natural assets in improving health and reducing inequalities.
I hope the Minister will assure us that the Government recognise the indispensable role of the arts and culture, as well as engagement with nature, in mitigating health inequalities, and that the system created by the Bill—designed, I hope, with an unambiguous purpose to reduce health inequalities—will fully embrace such non- clinical approaches.

Lord Patel: My Lords, I thank the noble Baroness, Lady Thornton, for introducing this group of amendments. My name is attached to her amendments, and I have some amendments in my name; I thank noble Lords who have added their names. I will speak in particular to Amendments 11 and 14 but what the noble Baroness, Lady Thornton, said applies to other amendments, and I agree with them and have added my name to them.
Covid-19 has exposed and exacerbated existing health inequalities in England, and the Government have committed to “levelling up” the country. Progress on national NHS commitments related to reducing health inequalities has been slow in recent years, and NHS England has urged local systems to accelerate action to tackle health inequalities after the pandemic. A step change is clearly needed, yet the Bill’s current provisions on health inequalities amount to no more than the same: transposing existing inequality duties from CCGs to the new NHS ICBs.
One area where there is clearly scope for improvement is strengthening reporting on health inequalities. There is currently no explicit requirement for NHS England to publish national guidance about which performance data and indicators relevant to health inequalities should be collected, analysed and reported on by NHS bodies. The NHS’s current system oversight framework, as a means to define national priorities and monitor the overall performance of local systems, also includes little in the way of concrete measures on health inequalities, with those that are included being focused primarily on shorter-term Covid-19-related equity impacts.
The amendment in the name of the noble Baroness, Lady Thornton, addresses this. It would require NHS England to publish guidance on collecting, analysing, reporting and publishing data on all factors or indicators relevant to health inequalities. I hope the Government will commit to considering this amendment in order to drive more action on inequalities and enable better tracking of progress across different areas.
The only thing I would add to this is the NHS Priorities and Operational Planning Guidance that was published by NHS England just before Christmas—in fact, on 24 December; it could not be much nearer to Christmas. On page 6 of this, as one of the priorities for 2022-23, NHS England asks local health systems to:
“Continue to develop our approach to population health management, prevent ill-health and address health inequalities—using data and analytics to redesign care pathways and measure outcomes with a focus on improving access and health equity for underserved communities.”
It also states that in delivering all the NHS’s priorities, it intends to maintain the
“focus on … tackling health inequalities by redoubling our efforts on the five priority areas”—
already mentioned by the noble Baroness—
“set out in guidance in March 2021.”
It reiterates that ICSs will take a lead role in tackling health inequalities and notes:
“Improved data collection and reporting will drive a better understanding of local health inequalities in access to, experience of and outcomes from healthcare services, by informing the development of action plans to narrow the health inequalities gap. ICBs, once established, and trust board performance packs are therefore expected to be disaggregated by deprivation and ethnicity.”
On page 29 onwards there are further details about this.
Amendment 11, in the name of the noble Baroness, Lady Thornton, to which I have added my name, therefore goes with the grain of current policy and would help support these efforts and put this in the legislation. Arguably, it will not be possible to do this effectively without more consistent guidance and clarity around how to measure progress on inequalities, which is what the amendment seeks to do. I am led to believe that NHS England might be supportive of this and clearly thinks it is needed to spur action.
I turn very briefly to Amendment 14, which relates to the “triple aim”. I strongly support Amendment 14 —in the name of the noble Baroness, Lady Thornton, and others—which aims to extend this. To send a clearer signal about the importance of narrowing inequalities, the triple aim should be extended so that it explicitly references the need for organisations to consider the impact of their decisions on efforts to reduce inequalities.
The Government so far have argued that addressing inequalities is already implicit in the first aspect of the triple aim—the requirement to consider the effects of decisions on the health and well-being of the population. It has clearly not been obvious to many experts and charities scrutinising the Bill. However, if it is the Government’s intention to ensure that the reduction of inequalities is prioritised, they should make this explicit in the Bill.

Lord Young of Cookham: My Lords, this is my first contribution to the debate on the Bill and, listening to earlier exchanges, it struck me how many were being made by those who had either run the NHS as administrators or, indeed, as Ministers. I can join that happy band. I was a Health Minister in 1979 and put on the statute book the Health Services Act 1980, abolishing area health authorities. Nostalgia has overcome me, as phrases I used 40 years ago about streamlining the structure and making it more efficient have been recycled in debates on this Bill.
My first piece of health legislation followed the appointment of commissioners to run the Lambeth, Southwark and Lewisham Area Health Authority which was breaking its cash limits and behaving illegally. Unfortunately, our suspension was also illegal, and I had to pilot through the other place the National  Health Service (Invalid Direction) Bill, with much hilarity at my expense from the Opposition. So, more than 40 years later, it is good to join in another debate about NHS reorganisation. Today’s debate about inequality was actually raised 40 years ago: noble Lords may remember the Black report on inequalities in health. I was rereading it last night and it struck me how many of the 37 recommendations made 40 years ago are still relevant today.
Mine is the lead name on four amendments, but I plan to say very little on Amendment 66 and leave it to the noble Lords, Lord Rennard and Lord Faulkner, to make the case for a specific reference to smoking as a key factor in reducing health inequalities.
As we have heard, the Bill gives integrated care boards a responsibility to reduce inequalities in access to health services and in health service outcomes. The biggest cause of inequalities are factors such as smoking, obesity and alcohol, particularly smoking, which is responsible for half the difference in life expectancy between the richest and poorest in society—an issue that was raised an hour ago during Oral Questions. Others will say more about the imperatives of tackling these hazards to health.
I will focus instead on Amendment 152 in my name and will also speak briefly to Amendments 156 and 157. These amendments are supported by the noble Lord, Lord Shipley, who will focus on housing and why legislation is necessary, and by the noble Baronesses, Lady Neuberger and Lady Watkins. I am grateful to Crisis, the homeless charity, for its briefing.
I commend the Government’s welcome commitment to tackle health inequalities and hope the forthcoming White Paper on levelling up will have a strong section on this, following the recent report of the Public Services Select Committee, chaired by the noble Baroness, Lady Armstrong. I hope that will put flesh on the bone of what risks becoming more of a slogan rather than a policy, meaning different things to different people. I hope the levelling up White Paper will directly address inequalities in health.
As the Secretary of State for Health has said recently, we must tackle the “disease of disparity”, and these amendments highlight the experiences of those groups who are undoubtedly at the worst end of that disease. In current NHS policy and documents, these groups are referred to as “inclusion health populations”—a term used to highlight the need for health services to overcome the social exclusion and marginalisation that many people face, resulting in dire consequences for their health. That group includes rough sleepers, Gypsy, Roma and Traveller communities, vulnerable non-UK nationals and people with substance misuse issues.
These people develop health conditions usually seen in people in their 70s and 80s up to 40 years earlier, and often die from them. Tragically, the average age of death among people experiencing homelessness is 46 for men and 42 for women. Clearly, these are not health outcomes we should accept for anyone. The solutions exist, and chime very well with what the Health and Care Bill seeks to do. However, it currently does not go far enough.
The Bill places a welcome emphasis on integrated services. To tackle the health injustices for people who are socially excluded, we need holistic, integrated health  services to meet their needs, and we need them everywhere. They do exist in some places; they are also referred to as “inclusion health services” and they have a significantly positive impact. For example, Pathway, the leading health charity for inclusion health, has helped 11 hospitals in the UK create multidisciplinary teams of doctors, nurses, social care professionals and housing workers. These teams support over 4,000 patients every year who are homeless, with very positive outcomes. An audit of Pathway’s services in 2017 showed a 37% reduction in A&E attendances, a 66% reduction in hospital admissions and an 11% reduction in bed days. However, despite these successful services, inclusion health services are not currently commissioned at the scale required, and access to them is a postcode lottery. King’s College London found that 56.5% of homelessness projects in England do not have a specialist GP inclusion health service in their area—hence the amendments on best practice.
During my time as a Housing Minister, I saw the impact of social exclusion on people, including how not having a stable home to live in is devastating for people’s physical and mental health. Therefore, working closely with expert organisations across these sectors including Crisis, Pathway, St Mungo’s and many others, we want to amend the Bill to ensure a strategic focus in the new systems being set up to help the most socially excluded in our society.
The amendments introduce two important and necessary changes. The first would place a duty on integrated care partnerships to have due regard to the need to improve health outcomes for inclusion health populations when they create their healthcare strategies. Placing a duty on partnerships will make it clear that inclusion health is a strategic focus, and that should follow through and be reflected in the resourcing and commissioning decisions of integrated care boards. I do not regard the requirement to “have regard to” as an onerous imposition.
The second change would make clear the importance on health outcomes of having a stable home. It would mean that, in addition to the partnership having to consider health and social care in its strategic integration arrangements, it would also need to consider housing. This possible change would make clear that housing is on a par with health and social care services. The noble Lord, Lord Shipley, will say more about this.
With the advent of the Everyone In scheme in March last year, which sought to provide safe accommodation for those who without it would have continued to sleep rough, we saw how critical it is for people to have a place of their own. We need to build on that success and prevent rough sleepers drifting back on to our streets. My amendment legislates to ensure that health, social care and housing services continue to work more closely together to consistently support people who too often fall through the gaps between these services.
These amendments are firmly within the scope of the Bill. They will complement and strengthen its welcome aims to integrate health services across the whole system and tackle health inequalities. The amendments are neither overly prescriptive nor bureaucratic; their aims are simple. I look forward to my noble friend the Minister’s reply.

Baroness Greengross: My Lords, in October last year, during the debate on the Ageing: Science, Technology and Healthy Living report, the Minister, the noble Lord, Lord Kamall, confirmed that the Government maintain their commitment to ensuring that people live at least five extra healthy and independent years of life. A practical first step towards achieving that goal would be to ensure that tackling health inequalities is a priority in this legislation, and the amendments in this group seek to achieve that. We know that health inequality is a problem that has been getting worse, and we need to tackle it as an emergency. I support the amendments in the group calling for NHS England, NHS trusts and the integrated care strategy to collect relevant information and data, as well as to take the necessary action to prevent health inequalities and improve healthy living.
In 2010, as we know, Sir Michael Marmot published his report on health equity, finding that social position determined people’s health outcomes and that people at the lower end of the social gradient had worse health. At the time, the report recommended that the focus on improving this should not be targeted just at those from the most disadvantaged parts of the country but should take a universal approach to improving health outcomes, which is very much needed. The report highlighted the economic benefits of addressing health inequalities. In particular, it raised the issue of lost productivity, increased spending on welfare and lost tax revenues due to people having to leave work as a result of poor health.
Just before the pandemic, in 2020, Sir Michael Marmot did his 10-year review, and we know how alarming the findings of that report were. For the first time, life expectancy had stalled in the UK. In the poorest 10% in England, the life expectancy of women actually declined between 2010 and 2012 and between 2016 and 2018. Mortality rates for people between 45 and 49 years old increased, and in many cases those were deaths of despair, due to suicide or substance abuse. That is terrible news. The level of child poverty has also increased in the UK to 22%—compare that with Norway, for example, where child poverty is 10%. That is also alarming. The number of years lived in poor health across England has increased and continues to be worse in the poorest parts of the country.
We hear much about the so-called levelling-up agenda from the Government. One finds it hard not to dismiss it as little more than a glib and somewhat trite slogan, because there is little to back it up in real policy to try to address issues such as health inequality. However, I am an optimist and I see the Bill as a step towards trying to address these challenges. But to do this effectively we must have a better understanding of the drivers of health inequality. We must have plans at a local and national level to address those drivers. This group of amendments offers some solutions to start addressing health inequalities through this legislation. I look forward very much to the Minister’s response to these amendments and to hearing his view on how the Bill is going to achieve the Government’s goal of people living at least five extra healthy and independent years of life.

Baroness Tyler of Enfield: My Lords, my name is attached to six amendments in this extremely important group. I should like first to turn to Amendment 14 in the name of the noble Baroness, Lady Thornton, to which my name is attached. Other noble Lords have expressed support for amending the triple aim to explicitly include health inequalities, and I add my voice to that call. The examples given by the noble Lord, Lord Patel, and others about the real-life causes and impacts of health inequalities show just how important it is that we strengthen the Bill.
I would like briefly to highlight the specific impact of mental health inequalities, which are pervasive and deeply embedded. As the noble Lord, Lord Crisp, said in our debate on Tuesday, mental illness itself causes inequality. People with severe mental illness live, on average, between 15 and 20 years less than the general population. Black people are more than four times as likely as white people to be detained under the Mental Health Act. There are higher rates of suicide in the LGBT community, yet many in that community do not, or feel that they cannot, seek healthcare because of fear of discrimination. People with a learning disability often suffer with significantly worse physical and mental health than the general population.
The Centre for Mental Health Research has shown that it is often groups of people with the poorest mental health who have the greatest difficulty accessing healthcare that meets their needs and produces good outcomes for them. Unless an ICB is focused on which groups of people have the poorest health in the first place and understands why that is the case, it will, frankly, struggle to reduce the inequalities flowing from that.
Amendment 14 would amend the triple aim duties specifically for NHS England. Amendments 94, 185 and 186 in the name of the noble Lord, Lord Patel, to which I have attached my name, would replicate that explicit inclusion in the triple aim for integrated care boards, NHS trusts and NHS foundation trusts.
As the noble Lord, Lord Young, has said on health inequalities, regarding them as implied in the first element of the triple aim—to consider the impact of decisions on the health and well-being of the population—does not, in my view, get us any further than where we are today. Given the statistics that I have outlined and the fact, as we have heard, that the pandemic has made things a lot worse, we clearly need to go further.
I turn now to Amendment 65, regarding the role of local health systems. It seeks to strengthen the health inequality duty placed on integrated care boards by giving them a requirement to
“implement systems to identify and monitor inequalities in physical and mental health between different groups of people within the population”
of their area. As things stand, the provisions in the Bill will ensure that NHS organisations are required to address inequalities in a similar way to how CCGs currently do it. But we need to see more ambition. The provisions would be strengthened and not merely transferred. The current requirement to “have regard to” is not enough. Local health systems have a central role to play in addressing health inequalities. They are ideally positioned to understand the challenges in  their areas and, to use the jargon—for which I apologise —co-produce local solutions with communities. The development of integrated care systems gives us a new opportunity for local areas to take population health and place-based approaches, so that the vulnerable groups who have been referred to do not fall through gaps.
There is a lot about health inequalities that we do not know; we suspect, but we just do not have the data. Amendment 65 proposes that the Bill includes clearer and more direct requirements for integrated care boards to focus efforts on identifying and monitoring those inequalities. Currently, the quantity and quality of data collected is inadequate for it to be fully disaggregated against the different protected characteristics and provide a real insight into the inequalities that exist. That is why I have attached my name to Amendment 61 in the name of my noble friend Lady Walmsley, which I strongly support.
Robust information and data are prerequisites for any action. Improved data collection—both on health services and on wider inequalities in the area—will lead to a far better assessment of what needs to be done, particularly in areas such as public mental health and the local NHS workforce. I will quote one statistic about GPs. A GP working in a practice serving the most deprived patients will, on average, be responsible for the care of almost 10% more patients than a GP serving a more affluent area. This simply cannot be right.
I will end by quoting from work we have already heard about—the work of Professor Sir Michael Marmot. It needs no introduction. He has demonstrated that efforts to address health inequalities will benefit society as a whole. The NHS Long Term Plan states:
“While we cannot treat our way out of inequalities, the NHS can ensure that action to drive down health inequalities is central to everything we do.”
I urge the Government to ensure that the Bill does just that.

Lord Desai: My Lords, as an NHS patient but not an expert, I will say one small thing about inequalities. Given the way in which the NHS is structured, with no money paid up front and with excess demand and inadequate supplies because of budget shortages, it is forced to allocate treatment by queuing—and queuing, obviously, means that people have to wait.
There is a fallacy that somehow the poor have more time than the rich. In my experience it would improve matters immensely if, when appointments are given, there was less delay in the patient seeing the person whom they are supposed to see. I know that, right now, there are standard regulations that cover these matters, so that people end up waiting three hours. I have done that. But my time is not as valuable as that of someone poorer. You do not measure the value of your time by your income. So it would improve matters if the allocation of services were made using communication devices. This would waste less of patients’ time and help them better access services.

Bishop of Carlisle: My Lords, I will speak on behalf of my noble friend the right reverend Prelate the Bishop of London. She has added her name to Amendment 65, and we on these Benches support the other amendments in this group that seek to reduce  health inequalities. As we have heard, these amendments would help to ensure that the Bill does not forget the underserved and disadvantaged in our society, many of whom have been mentioned already.
In the Christian and Jewish faiths, there is a Biblical concept—shalom—which embodies a sense of flourishing, generosity and abundance. Shalom can be summarised as experiencing wholeness, or a state of being without gaps. This is reflected in the World Health Organization’s definition of health, which is about not only the absence of disease but mental, physical and social well-being. It is a vision for individuals and for the whole of society. Our efforts to design a more holistic health service are, in effect, aimed at achieving that sort of shalom. We see this clearly in the decision made to place 42 integrated care systems across the country. What is not yet apparent is the relationship of these systems and boards to the wider community.
This Bill must seek to involve local communities—and not just professionals—in the reduction of health inequalities. These amendments highlight the monitoring of both physical and mental inequalities, take account of the experiences of young people and children and place more emphasis on the strength of local interventions to help reduce and prevent health inequalities. I commend them wholeheartedly to your Lordships’ House and to the Minister.

Lord Rennard: My Lords, I rise in support of these amendments, in particular Amendment 66 in my name and those of the noble Lords, Lord Young of Cookham and Lord Faulkner of Worcester.
This amendment would expand the duties of integrated care boards. We want them to exercise their functions with respect to reducing inequalities relating to
“modifiable risk factors, such as smoking.”
Our aim is to help the Government achieve their manifesto commitments to reduce health inequality, level up and increase healthy life expectancy by five years by 2035. This amendment would mean that integrated care boards would have a responsibility to reduce inequalities in access to health services and the outcomes achieved. They would also be responsible, in consultation with partners such as local health and well-being boards, for drafting joint five-year plans to explain how they would discharge their responsibilities, including those to reduce inequalities.
At present, there are significant inequalities in both patient access to health services and in the outcomes achieved. The biggest causes of inequalities in health outcomes are behavioural risk factors, such as smoking, obesity and alcohol. As the noble Lord, Lord Young of Cookham, said, smoking alone is responsible for half the difference in life expectancy between the richest and poorest in society. It is a greater source of health inequality than social position and it remains the leading cause of premature death in this country.
We all hope that the integrated care systems will contribute significantly to reducing inequalities in smoking and other behavioural issues, but they are likely to succeed only if addressing such modifiable risk factors becomes a core function of the NHS, working in collaboration with local authorities. Amendment 66 would ensure this.
The difference in healthy life expectancy between those living in the most and least deprived areas of England is around 19 years for both men and women—in other words, almost two decades. Let us look at one place in particular. As measured by the index of multiple deprivation, Blackpool is, sadly, top of the table of the most deprived local districts in the country. Over the last decade it has consistently had one of the highest smoking rates in the country, at over 20%. Most distressingly, more than 20% of mothers in Blackpool are smokers at the time they give birth. So our amendment is needed because the recently published NHS inequalities strategy—which is impressive in parts—does not address the behavioural causes of health inequalities. In fact, it says nothing about them at all.
The Government’s inequality strategy sets out five clinical areas that are crucial to improving health outcomes for the poorest 20% in society. They are chronic respiratory disease, serious mental illness, early cancer diagnosis, maternity and—last but not least—identifying people with high blood pressure who need to be pre-treated to prevent heart attacks and strokes. In all these areas, behavioural factors such as smoking, obesity and alcohol very significantly increase the dangers to health. If appropriate action is taken, it can greatly improve patient outcomes and, at the same time, reduce pressure on our NHS.
To take just one example, chronic respiratory disease is caused primarily by smoking. It is estimated that smoking is responsible for 90% of chronic obstructive pulmonary disease, but one-third of patients diagnosed with COPD carry on smoking. There is nothing in the NHS England inequalities strategy about this, and no target for reducing smoking rates among those with chronic respiratory disease. Yet stopping smoking is the most effective and cost-effective treatment. Only by quitting smoking can those with COPD prevent further decline in lung function.
Smoking, obesity and alcohol are also causally linked to cancer and hypertension. People with mental health conditions die on average 10 to 20 years earlier than the general population. Smoking is the single largest factor in this shocking difference. The question we must therefore ask today is this: given that modifiable behaviour risk factors are core to all five identified clinical focus areas, why are they not included in the NHS England inequality strategy? Perhaps it is because the Government do not see addressing these population-level health risk factors as a core responsibility of the NHS.
Could it be that the Government are leaving the responsibility for such issues to local government despite knowing that local authorities have greatly diminished resources at the same time as they face considerably increasing costs to fund activities for which they have legal obligations? Addressing modifiable risk factors should be core business for the NHS and local authorities working together. At every level, we need to recognise that funding activities such as smoking cessation services extends people’s lives, improves their quality of life and saves the NHS significant sums of money in the long run.
Amendment 66 therefore seeks to make smoking and other modifiable risk factors to health the responsibility of integrated care systems and local authorities, which must work together if we are to improve public health, with all the benefits that follow, including helping to protect our NHS.

Baroness Watkins of Tavistock: My Lords, I am delighted to speak to this group of amendments, which I support; I am particularly delighted to speak to Amendment 156, as one of its co-sponsors. I very much support the comments of the noble Lord, Lord Young, who has highlighted the appalling health disparities faced by people who are the most socially excluded. I, too, ask the Government to recognise how amending the Bill in the way proposed would help them to realise their ambitions in this area.
We know that the level of ill health among people who would be considered under inclusion health is significant. We have heard the shamefully low average age of death for people experiencing homelessness in England and Wales. We also know that the life expectancy of Gypsy, Roma and Traveller communities is around 10 to 12 years fewer than that of the general population, although one study has found that this gap can be as high as 28 years. This disparity in life expectancy clearly demonstrates the devastating impact of extreme social exclusion.
It is clear to me that the health and social care system has a significant role to play in tackling the health inequalities experienced by these groups. These amendments would facilitate crucial progress towards that and encourage social enterprise involvement to reach the most socially excluded individuals. We have seen examples of this at the relatively new Plymouth dentistry school, where the training clinic has been set up as a social enterprise to serve some of the poorest people in Plymouth.
In relation to Amendment 156 in particular, we know that NHS services must be integrated with wider services to reflect how people’s lives work. A main aim of the Bill is integration, yet integration could not be more important for the groups that experience the most complex needs and require very effective, co-ordinated care. As I know from my time in nursing, there has been a historic lack of integration between housing, health and social care, yet housing is fundamental to reducing health inequalities. Without integration across these different systems, people will continue to develop acutely poor health.
People who experience social exclusion, and extreme health inequalities as a result, often fall through the gaps in the provision of primary and secondary care, mental health and substance misuse services, health and social care, and even health and wider systems, such as housing. For example, we know that people experiencing homelessness attend A&E six times as often as people with a home, are admitted to hospital four times as often, and stay three times as long. One study has found that homeless people attend A&E 60 times more than the general population. This has tragic results for the individual and also places incredible strain on our healthcare system.
We must act to alleviate the pressures on the NHS where we can. Severe and multiple disadvantage is conservatively estimated to cost society more than  £10 billion a year. It is clear that the cost of doing nothing is too high, both to the individual suffering severe health inequalities and to the NHS. This amendment would help address these issues by ensuring that housing is considered by integrated care partnerships. It is non-mandatory, therefore speaking to the Government’s aims of enabling local decision-making and flexibility, but would ensure that partnerships think of the important role that housing plays by providing a stable place from which people can then engage with wider health services. A wide range of expert organisations are supportive of this amendment and related Amendments 152 and 157, including Crisis, Social Enterprise UK, Doctors of the World, and Friends, Families and Travellers.
The NHS must work effectively for all who are entitled to use it, including those who need it most. If we get access and outcomes right for the most marginalised in our society—those who experience the poorest health —we will likely get access and outcomes right for everyone. That is why I call on the Government to support the amendments in this group.

Bishop of St Albans: My Lords, Amendments 68 and 95 are in my name. I declare my role as president of the Rural Coalition. I support the broad drift of these amendments, which engage with the important issue of reducing inequalities.
Rural health and social care has often presented challenges in terms of proximity to services, the types of services available within a local area and the demographics of rural areas. It is complicated. Rural areas have a higher proportion of older residents, which is always a greater burden on healthcare services compared with areas with younger populations.
Furthermore, a variety of issues that feed into rural health and social care are beyond the remit of the Bill. In March 2017, Defra produced its Rural Proofing practical guidance to help policymakers assess the impact of policies on rural areas. At the time, this was a welcome initiative to ensure that rural interests were being adequately considered and, to quote the report, that
“these areas receive fair and equitable policy outcomes.”
Unfortunately, concerns have since grown among rural groups that this guidance has become a sort of bureaucratic box-ticking exercise in Whitehall that does not take into account the complexities of rural life.
Funding allocations are often the result of specific metrics or formulas, many of which disadvantage rural communities. For example, a 2021 report by the Rural Services Network, Towards the UK Shared Prosperity Fund, highlighted how many of the post-Brexit levelling-up funds disadvantaged poor rural areas due to way in which they measured poverty. The Department for Transport’s own 2017 statistics showed that, on average, travel from rural areas to either a GP or hospital was 40% longer by car and 94% longer via public transport when compared with travel in urban locations.
Further, 2017 figures from Rural England highlighted the higher rates of delayed transfer of care from hospitals in rural areas: 19.2 cases per 100,000 compared with 13 per 100,000 in urban locations. Analysis by the RSN has shown that, when compared with predominately  urban areas, rural local authorities received significantly less grant funding per head to pay for services such as social care and public health responsibilities, in spite of the fact that they generally deal with older populations. Other problems include limited intensive care capacity in rural areas, the loss of local services through amalgamations, the relatively few specialist medical staff in rural areas, and the general staff shortage and retention issues facing rurality.
It is commendable that the Government have legislated in this Bill to introduce a duty on integrated care boards to reduce inequalities between patients with respect to their ability to access health services. My amendments would extend this principle and reduce those health inequalities with respect to where someone lives, whether it is an urban or rural area, and place a duty on ICBs to co-operate with each other for the purpose of reducing healthcare access inequalities. In effect, this is a statutory rural-proofing requirement.
This duty to consider rural access when reducing inequalities extends to co-operation between ICBs because rural areas often exist on the periphery of a large geographical region where patients in one area may reside closer to crucial services in a neighbouring board. Naturally, rural areas lack the economies of scale of urban areas, and greater cross-ICB co-operation will be required to utilise joint resources most effectively when delivering different services to rural areas that fall within border zones of ICBs.
One area where a collaborative approach between ICBs will be crucial for rural areas in the near future is the current reorganisation of non-emergency patient transport by NHS England, which will shift to ICBs shortly. Although rural areas undoubtedly are being considered as part of this re-organisation, patient transport is already a rural inequality that needs addressing. Putting rural proofing with respect to health care on a statutory footing presents a more concrete way to implement the existing rural-proofing guidance. The need for co-operation between administrative areas and for overall plans to be rural proofed will become more essential, particularly for secondary health services, if teams of specialist clinicians become increasingly consolidated in ever fewer locations.
Can the Minister outline how the Government intend to reduce the inequalities in healthcare access and funding that many rural areas face, and how they will effectively ensure that ICBs adequately rural proof their plans in line with the Government’s own guidance?

Lord Faulkner of Worcester: My Lords, I am very pleased to follow all noble Lords in supporting all the amendments in this group. I congratulate my noble friend Lady Thornton on the way in which she introduced the debate when moving Amendment 11. I will speak briefly to Amendment 66, which was tabled by the noble Lord, Lord Young of Cookham, and signed by the noble Lord, Lord Rennard, and me.
It was enjoyable listening to the noble Lord, Lord Young, taking a voyage down memory lane to more than 40 years ago, when he was a Health Minister. He could perhaps have added that we would have become a smoke-free country rather earlier, had his advice and proposals for tobacco control been accepted at the  time, and had he not been removed from health on the instruction of Sir Denis Thatcher and given another role in government. He is and remains a pioneer, and I am delighted to be behind him with his amendments; we shall come to other smoking amendments later.
Amendment 66 would require integrated care boards to address the leading preventable causes of sickness and death, particularly smoking. The Bill as drafted fails to get to the root causes of health inequalities and will have only a limited effect. Our amendment would correct this oversight as far as smoking is concerned. In 2019, there were 5.7 million smokers in England, one in seven of the adult population. As the noble Lord, Lord Rennard, said, in England smoking is the leading cause of premature death, killing over 70,000 people a year and leaving 30 times as many suffering from serious smoking-related disease and disability.
As Sir Chris Whitty, the Chief Medical Officer, said in a lecture on public health at Gresham College last May, smoking is likely to have killed more people in 2020 than Covid-19, but unlike Covid-19, smoking kills on the same scale every year, and will go on doing for many years without robust action to correct this. It is worth pointing out that he also said that one in five people who die from cancer will die from lung cancer, and
“the reason that people like me get very concerned and very upset about it is that this cancer is almost entirely caused for profit. The great majority who die of this cancer … die so that a small number of companies make profits from the people who they have addicted in young ages, and then keep addicted to something which they know will kill them. So lung cancer is unfortunately still a very major problem”
that exists almost entirely because of smoking for profit.
While overall smoking rates have fallen significantly over the last 20 years, the difference in smoking rates between the most disadvantaged group and the general population has become more pronounced: the inequality has widened. This includes people with mental health conditions, pregnant women, those in routine and manual occupations, and those living in social housing. There is a real risk that people from these groups will be left behind as we move towards a smoke-free 2030.
Given current trends in smoking, Cancer Research UK has estimated that we will miss the smoke-free 2030 target by seven years, and the most deprived quintile will not reach the target until the mid-2040s. This amendment will help to ensure that this prediction does not become reality. The Government announced their ambition to make England smoke-free by 2030 in the 2019 prevention Green Paper. However, in the two years since, we have seen no sign of the “bold action” that the Government acknowledged is needed to achieve the 2030 ambition.
In December 2020, the Government announced that a new tobacco control plan would be published in July 2021 to deliver that ambition. This did not happen and last month, the Minister, the noble Lord, Lord Kamall, told Parliament that publication had slipped to 2022, with no date specified. With only eight years left until 2030, there is an urgent need for action to back up the Government’s rhetoric. This Bill is a great  opportunity to get us on track to deliver a smoke-free 2030, and to tackle the severe health inequalities plaguing our society. I urge the Government not to squander this opportunity and to accept this amendment, along with the other amendments on smoking which we will come to later in Committee.

Lord Shipley: My Lords, now that we are in Committee, I remind the House of my interest as a vice-president of the Local Government Association. I rise to speak to Amendments 152, 156 and 157, to which I am a signatory. I will not repeat all the excellent points made by the noble Lord, Lord Young of Cookham, and others, but I hope the Government will accept that what is being proposed is central to the success of this Bill, and that is because the NHS does not exist in a vacuum.
We know that prevention and early treatment of people’s ill-health will help them, reduce demand for hospital beds and lead to a more efficient use of public resources. We know well enough that poor housing contributes to poor health. These amendments to Clause 21 present an opportunity for the Government to demonstrate their commitment to truly tackling health inequalities and, in particular, to ending rough sleeping, by the end of this Parliament in 2024. As the noble Lord, Lord Young, and others have clearly laid out, the beneficial impact on a range of groups experiencing social exclusion and poor health outcomes would be significant. That means that there must be integrated approaches between housing, health and social care at the point when integrated care partnerships create their healthcare strategies.
Research shows that an average local authority might have around 1,400 people a year experiencing multiple disadvantage, including support needs around mental and physical health, homelessness and contact with the criminal justice system. Around 58,000 people a year experience the most severe disadvantage. It is therefore essential that local integrated care partnerships consider all the ways in which health intersects with housing.
I was concerned to read recently that in July last year 77% of women leaving our largest women’s prison became homeless. Homelessness inevitably leads to poor health. As Professor Dame Carol Black’s recent review of drugs highlighted, unless housing and housing support needs are addressed, the health service will fail to improve people’s health consistently, regardless of how effective the commissioned health services may be.
We know this approach works. The Government’s welcome effort to vaccinate people who were homeless went alongside a push for not only GP registration but provision of emergency accommodation. This acknowledged the need to bring together support into housing alongside access to basic health services. Indeed, we have seen the Government revisit this approach just before Christmas, with the Protect and Vaccinate scheme. Since the Government have recognised the need for this integrated approach, I cannot see why they would object to these amendments that would help continue it.
Amendments 152, 156, 157 and others seek to make our NHS systems more effective in the delivery of services to the most excluded and marginalised in our  society. As it stands, people are forced to attempt to navigate a siloed and fragmented health service that does not adequately address their complex health needs. For example, one patient with alcohol and other addictions, supported by Changing Lives, could not access mental health services until after his alcohol addiction was addressed. However, with the right support from Changing Lives’ inclusion health approach, this patient is now managing abstinence from alcohol and engaging with mental health support. Crucially, his experiences highlight the challenges in addressing substance misuse in isolation, without making support available to address mental ill-health at the same time.
The Government may argue that it will be sufficient to address these concerns in guidance, but I hope they do not. I acknowledge that guidance would be beneficial in ensuring that approaches to inclusion health populations are considered within integrated care systems. However, without legislation, tackling inclusion health would become nice to do rather than something that must be done.
A recent example of this is Covid-19 vaccine uptake among people who were homeless. We know that where inclusion health services existed, there was a concerted effort to ensure good vaccine uptake, but without these specialist services we simply do not know how effective vaccination programmes have been. The only data available from July 2021 show vaccination rates to be substantially lower among people who were homeless compared to the general population.
I am aware that commissioning strategies and services for inclusion health populations is already on the agenda of some integrated care systems, but we need all integrated care systems to play their part. Guidance will not be effective enough to ensure the provision of specialist support everywhere, not just in some places.
In conclusion, the level of complexity of the marginalised and excluded experience can be met only by embedding inclusion health throughout the health and care system at the highest levels. Legislation is the most secure way to achieve this. Otherwise, there will continue to be a postcode lottery in access to the right healthcare services for these groups, resulting in that “disease of disparity” the Secretary of State wants to address.

Lord Kakkar: My Lords, I first join other noble Lords in thanking the noble Baroness, Lady Thornton, for the thoughtful way in which she introduced this group of amendments. I support Amendment 14, in the noble Baroness’s name, and Amendments 65, 94, 186 and 195 in the name of my noble friend Lord Patel. This is a vital group of amendments, as your Lordships have already heard, because it is focused on inequalities. Clearly, no society, Government or Parliament can tolerate the inequalities that we see in both clinical outcomes and access to healthcare that have remained despite our remarkable healthcare system and the NHS. It is for that reason that it is absolutely right that, in the opportunity afforded by this Bill, inequalities are properly addressed.
More worrying is that, despite this country’s substantial investment in healthcare and the development of health systems over the past 70 years, these disparities in outcomes and access to healthcare described geographically and across different ethnicities and socioeconomic groups  have continued to grow. That is despite all the success we have seen more broadly in delivering healthcare, addressing prevention and improving treatments.
It is also right to recognise that inequalities in outcomes and access to healthcare are best addressed at the local level. Through a focus on integration in not only the capacity of services but the capacity to integrate the development of policy and its execution across healthcare and through local government and the other elements of the state—education, employment, housing and so on—we will have the greatest opportunity to address social determinants of health. There has probably been no other health Bill presented to this Parliament since the creation of the NHS that provides the greatest opportunity to take that combined and collective approach.
It is therefore quite right that one turns attention to the triple aim. This is a laudable addition to the Bill, with an absolutely appropriate focus on promoting health and well-being, ensuring access to quality care for all citizens and ensuring the appropriate and effective utilisation of healthcare resources. Why not add to that triple aim a fourth clear objective to address issues of inequality? The triple aim does not mandate action, but it provides the context in which a framework should be developed locally, cognisant of the healthcare needs of the local population. An ideal framework would ensure that we drive collaboration and co-operation as required to focus activity and the allocation of resource and establish a local vision and determination to address health inequalities.
To fail to take this opportunity would be disappointing and, quite frankly, unacceptable. As we have heard in this excellent debate, if we fail to address these inequalities not only will they have a continuing and profound impact on health outcomes and access to healthcare for large numbers of our fellow citizens, but there are broader societal and economic consequences of continuing to accept inequalities in healthcare. I hope that, in answering this debate, the Minister will be able to confirm that Her Majesty’s Government are prepared to consider this issue and will put inequalities the heart of this Bill in the triple aim—becoming a quadruple aim—and will ensure that, at a local level, data collection and reporting become a primary focus of healthcare systems.

Baroness Harding of Winscombe: My Lords, I begin by declaring my interest as the recently departed chair of NHS Improvement. I support these amendments, especially those that seek to extend the triple aim, such as Amendments 14, 65 and 94, as the noble Lord, Lord Kakkar, just set out so eloquently. It seems there is no disagreement in the Committee about the importance of addressing health inequalities. Anyone who has lived through the past two years can see that plainly and clearly, as Covid has so cruelly highlighted the health inequalities in this country. The question is how we make sure this Bill genuinely tackles the issue that we all agree about so passionately. Why is it important, as just set out by the noble Lord, Lord Kakkar, to put the duty to address health inequalities in the Bill?
I want to make as my contribution a short story about a visit that I made recently in my capacity as chair of NHS Improvement with the noble Lord, Lord Mawson,  to north-west Surrey last summer. We visited the team from the NHS trust, Ashford and St Peter’s, as well as the local authority and a number of local community organisations. There was a moment in that visit when the medical director of the trust, a cardiac surgeon, said that he had had an epiphany: the NHS was not the most important actor in addressing health inequalities. He said that had hit him like a train; he had realised that he and his trust, by far the biggest organisation in the integrated care system and the largest employer with the most money, needed to play a supporting role rather than the prime-moving, main acting role. That was a huge culture shift for him and for the trust that he was part of. Over the course of the last couple of years, it has led them to do some small but hugely important things, such as relocating their physiotherapy clinics to gyms, which means that people get more into the habit of exercising when their NHS treatment ends. That requires the NHS to be subservient to the local authorities, voluntary organisations and private sector partners in their integrated system. If we are really to address health inequalities, that requires change from our beloved NHS.
The system that I am describing is one of our very best but they would openly admit that they are still in the early stages of that change, which is why it is so important that we put this in the legislation. I know that the Minister and the Secretary of State care deeply and passionately about addressing health inequalities; both have been very public about their commitment. I urge them to hear the spirit of the cross- party agreement in this Committee today and accept the amendments.

Baroness Pitkeathley: My Lords, I support all the amendments in his group but particularly Amendment 68, in the name of the right reverend Prelate the Bishop of St Albans, about health inequalities faced by those living in rural areas. When you live in a rural area, it is often difficult physically to access a GP practice—if you do not have a car, try getting a bus in a rural area whose timetable coincides with the opening hours of your surgery—and to access health information if your internet is not up to scratch. There are many rural areas where connectivity still leaves a great deal to be desired. Pharmacies, too, can be difficult to access; although some run outreach services, they are by no means universal.
In rural areas, the important non-clinical services mentioned by my noble friend Lord Howarth are largely dependent on the voluntary sector. During the pandemic, when village halls, with their plethora of exercise, dance, art and social support services, were closed, many older people in rural areas were cut off completely, with disastrous effects on their mental health.
The problems of delivering social care in rural areas are also well known. When care workers are paid for home visits only for the time when they are in the home and not for travelling time—time that will of course be extended by the spread-out nature of those visits—it is no wonder that many private and voluntary agencies are handing back social care contracts to local authorities because they simply cannot deliver them.
Poverty, the underlying cause of inequality, is more widespread in rural areas than is often acknowledged. Escaping to the country is a nice idea, but unless you recognise the particular inequalities faced by country residents, it is not as you see it on the television. Moving as a couple approaching retirement is a different picture when one—usually the husband, both the gardener and the driver—dies, leaving an isolated widow in declining health. The cost of fuel is also more acute in rural areas, and you will find many older people who may own a nice-looking cottage having to choose between heating and eating, with consequential effects on their health and future dependency.
I very much hope that when the Minister replies, he will emphasise that when integrated care boards are considering the provision of services for the purposes of achieving equality of access for patients, they will consider those living in all parts of the board’s area.

Lord Scriven: My Lords, this is my first intervention on the Bill. I draw the Committee’s attention to my relevant interests in the register, namely as a vice-president of the Local Government Association and a non-executive director of Chesterfield Royal Hospital NHS Foundation Trust.
I support this suite of amendments—particularly Amendments 11, 14, 65, 94, 186 and 195—which explicitly puts the issue of health inequalities in the Bill and makes it central to the aims of the NHS. It also deals with reporting and holding people to account for helping to reduce health inequalities.
The reason for my support is simple. I speak as a former NHS manager who, as a rookie many years ago, in the very early 1980s, was on the general management trainee scheme. For the first three months, our aim was just to go around. I remember asking the very naive question: “Who’s responsible for quality?” I expected the person who was showing me around to say, “Everyone”, but he said, “Follow me.” We went in his car for five miles outside the hospital to the health authority. We then went into a lift, down into the basement and through lots of corridors, and finally came to a door at the end of the corridor. The door was opened and in a dimly lit room was a middle-aged woman, surrounded by piles of paper. I said, “Who’s this?” I was told, “This is Gladys. Gladys is responsible for quality.” It was seen as someone else’s job.
That is why I have cringed a little when the Minister has said, in previous debates and Answers on health inequalities, that the Office for Health Improvement and Disparities is being established. That is well and good, but that office is not responsible for reducing health inequalities; everyone in the healthcare system and its partners must work together to reduce health inequalities. That is why it is really important that this is explicit. It is not just about health issues; it is about people’s income, work, environment, green space and transport. It should be explicit in the Bill as part of the triple aims—which will become four aims—and become part of monitoring. This issue must become central because something that I have learned about the health service is that unless the centre asks for it, and asks for it to be monitored, it just does not get done because it is not seen as important. That is why  monitoring this at both local and national level will hold people to account so it does not become Gladys’s responsibility.
The Bill gives us a once-in-a-lifetime opportunity not just to put health inequalities centrally in the Bill but to make them explicit in the way that the NHS and its partners work. With a little extra legal push to the mill, so to speak, as well as the monitoring, the data and holding people to account, I believe that we can finally start to deal with these issues in a systematic way that shows improvement and will allow the NHS and its partners to know where to push a bit harder to get this done. That is why I support the amendments.

Baroness Finlay of Llandaff: My Lords, this debate has shown clearly that attacking health inequalities must go beyond the bounds of the NHS as the impact of external factors is massive. I remind the Government that in 2015 poor housing alone was estimated to cost over £10 billion. That was in part because of the poor housing but it was compounded by inactivity and, as a result, obesity.
We should look at the antecedents of complex problems. Marie Curie’s report Dying in the Cold revealed failures in healthcare, bereavement and grief and the challenges of providing care for those with complex needs. Learning difficulties and autism, for which we often do not know the underlying causes, are disproportionately prevalent among people who are socially excluded and at high risk of homelessness, yet for them managing homelessness alone is particularly difficult because of their overall vulnerability. It has been estimated that autism alone has a twelvefold prevalence in those who are homeless compared to the general population.
The antecedents of many of the problems go back to childhood. They carry a life sentence of their trauma, which feeds into worsening health inequalities, aggravating factors such as alcohol and drugs consumption and other behaviours. Unless we strengthen the wording in the Bill to monitor and do something about the data that comes forward, the proposal of my noble friend Lord Kakkar—it is essential that we address this as a core problem to be tackled—will not be realised. I hope that when the Minister replies he will provide some assurance that the Government will consider strengthening the wording in the Bill in the light of this debate.

Baroness McIntosh of Hudnall: My Lords, I wonder if I might be allowed to speak at this point for the simple reason that I am shortly due to take over from the noble Baroness, Lady Fookes, in the Chair and if I do not contribute now, I will not be able to at all. I have no special expertise to bring to the scrutiny of the Bill, therefore this is the first time I have spoken on it and it may be the last. I want to speak in support of the contribution of my noble friend Lord Howarth of Newport, right at the beginning of what has been a very long and extremely interesting debate but which, until recently, when my noble friend Lady Pitkeathley mentioned it, did not refer back to the points he raised.
In making my brief remarks, I draw attention to my own interests, which are mostly to do with the arts. I am thinking about what my noble friend Lord Howarth  said about the arts sector and what it can contribute. I ask the Minister, when he comes to reply, if he would look to one side of his department—particularly towards the Department for Education and to the Department for Digital, Culture, Media and Sport—for further evidence, in addition to the very strong evidence my noble friend Lord Howarth put forward, of the impact of engagement with the arts, particularly on people suffering from often multiple disadvantages.
It is very clear that the data emerging in relation to education points to a strong impact on the health, particularly the mental health and well-being, of young people in education settings when they are able to engage creatively with the arts and arts practitioners. It would be very easy, in thinking about the huge diversity of issues that have been raised here which bear on health inequality, to see engagement with the arts as a “nice to have” extra—something that, if we get everything else right, we can perhaps add in. But it is more important than that, as the evidence is now strongly beginning to show. I therefore ask the Minister not to forget what my noble friend Lord Howarth said at the beginning of the debate in his reply, and to consider very seriously how health inequalities can be properly and creatively addressed by further engagement with the arts sector.
I will say one last thing, which perhaps seems not quite at the heart of it, but it is important. My noble friend Lord Howarth, in giving his examples, spoke about arts organisations, many of which are trying to contribute to this area. To be able to do that, they need people with skills who can deliver the work. Nearly all the people who can deliver the work and have those skills are freelancers. As we all know, they have suffered hugely in the last two years as a result of the crisis that we have all been through. Freelance workers in all sectors, but particularly the cultural sector, have had a very bad time and quite a lot of them have left. I add that as an additional thing to remember when we look at the expectations we can reasonably—and should—have of the arts sector. It needs to be able to properly support the people it has to engage to deliver the work that it can do.

Lord Mawson: My Lords, I did not want to speak in this part of the discussion but I will make a few comments. I absolutely support what the noble Baroness, Lady McIntosh, and the noble Lord, Lord Howarth, have been saying.
When I first arrived in Bromley-by-Bow 37 years ago this year, I found on my doorstep the largest artistic community outside New York and none of the systems had even noticed or understood its significance. Over the last 37 years, we have been exploring the whole arts and health agenda and the massive impact it can have on local people’s lives.
When we began to put the Olympic project together —as I said on Tuesday, I was involved in it from day one for 19 years—we took that really seriously and engaged with that large artistic and creative community in health, jobs and skills, education et cetera. That £1.2 billion development going on at the moment in the middle of the Olympic park, bringing together University College London, the London College of  Fashion, Sadler’s Wells, the V&A, the BBC orchestra and others, is all about this innovation agenda. It is moving it to scale. If this is to happen, we need the systems of the state and the public sector to learn from this entrepreneurial behaviour, which is happening on the ground, in real places and now to scale, and to understand the detail of what it means for the macro systems of the NHS.
I will say more about place later today, but I thank the noble Baroness for making those points, and the noble Lord, Lord Howarth, because this is fundamental. It relates to the fundamental question: what is a human being? A human being is fundamentally a creative being. Health and creativity and, I suggest, entrepreneurship and doing things, are fundamentally connected.

Lord Bethell: My Lords, I came face to face with the nation’s health inequalities every morning in the departmental Covid response group, the COBRA meetings and the COBRA gold, when we went through the hospitalisation details and ICU data and heard stories from the front line of how people who had comorbidities particularly associated with obesity were filling up our hospitals as the virus spread through the country in wave after wave. That health inequality hit this country hard in very real terms. It cost a lot of lives, caused a lot of misery and cost our health system an enormous amount of money. It cost this country and its economy a huge amount of money and it is time that we came to terms with that challenge and solved the problem.
As a number of noble Lords have pointed out, the NHS must step up to its responsibilities in this area. There are complex reasons for these inequalities; some are environmental, some are behavioural and some are to do with access. But the NHS and whole healthcare system must realise that it needs to be involved in all aspects of those, and prioritise and be funded accordingly. The Bill already does an enormous amount to change the healthcare system’s priorities. Putting population at the heart of the ICSs is one really good example of that.
To anticipate some of his remarks, I know that the Minister will point to the Office for Health Improvement and Disparities. As the noble Lord pointed out, however, it has a tiny budget and cannot take responsibility for the nation’s health. Our councils are stony broke, as I found in my experience of dealing with them over the last two years. There is no one else to do this; this is not someone else’s problem. This is to do with the British healthcare system, and it needs to stand up to that responsibility. Zero progress has been made in the round over the last few years and we have gone backwards in the last two years in a big way. We need to make this a massive priority.
This is a fantastic Bill; I am really supportive of it. It came from the healthcare system originally. In this one area, however, there is a graphic lacuna that needs to be addressed. The noble Lord, Lord Kakkar, put it so well in his inimitable way. The prioritisation of inequality must be put in the Bill and it needs to be heard throughout the healthcare system that this is the new, central priority that needs to be added to everyone’s job description.
If, for some reason, we do not do that there will be huge consequences. The healthcare system is unsustainable in its current form. We cannot continue to have a large part of the population carrying grievous comorbidities or disease and afflictions which are undiagnosed or not properly mended turning up in our hospitals at a very late stage and costing a fortune to mend. These health inequalities, whether they relate to disease, injury or behavioural issues such as obesity, are costing us a fortune. Only by putting tackling inequality on the face of the Bill can we really give it the priority it deserves.
I also say to the Minister that there is a sense of political jeopardy about this as well. We went into the last election committed to levelling up on health. We have gone backwards in the last two years through no fault of the Government, but if the Government do not step up to their responsibilities in this area, and if the NHS and the healthcare system do not change their priorities, the voters will judge us extremely harshly. For that reason, I urge the Minister to listen to this debate and look very carefully at ways of amending the Bill.

Baroness Neuberger: My Lords, I want to pay tribute, as other noble Lords have, to the noble Baroness, Lady Thornton, for her very thoughtful introduction. It is remarkable and absolutely wonderful to see consensus breaking out across the Committee. I will speak specifically to Amendments 152, 156 and 157 in the name of the noble Lord, Lord Young of Cookham, whose words on the need to make this really serious by stating it on the face of the Bill I echo.
I am a former chief executive of the King’s Fund and am currently chair of University College London Hospitals and Whittington Health. These issues are very dear to my heart and the hearts of those institutions. I also want to say thank you to Crisis for its briefing and add to the words of the noble Lord, Lord Young of Cookham, in praise of Pathway, which has done the most extraordinary work in this area over very many years.
I want to talk particularly about the NHS-funded Find & Treat service, which was set up 13 years ago and is run by UCLH, which I chair. This service was set up in response to a TB outbreak in London and aimed to provide care for people experiencing homelessness and people facing other forms of social exclusion. The service did exactly what it says on the tin: it went out and found people—and still does—who were at risk of contracting TB, wherever they were sleeping, and offered them diagnosis and treatment. Back in 2011, a study concluded that this service had been not only effective in helping to treat people with TB who were experiencing homelessness but cost effective in doing so, both in terms of costs saved to the health service and improved quality and length of life for the people receiving care. Fast-forward a decade and the evolution of this service meant it could be similarly mobilised at the beginning of the Covid pandemic. It provided urgent and necessary care to people who continue to experience the poorest health outcomes.
The King’s Fund published a report in 2020 on delivering health and care for people sleeping rough. It supported the need for inclusion health services to be  provided much more broadly than at present. Importantly, it also concluded that local leadership is absolutely vital in crafting that approach and said that local leaders should model effective partnership working across a range of different organisations.
Embedding inclusion health—I cannot say I really like the term, but everybody knows what it means—at the level of integrated care partnerships will help ensure that our healthcare system can no longer ignore, forget or overlook people who are all too often considered “hard to treat”, despite proven interventions showing the opposite. It will ensure that integrated care partnerships and systems take that vital first step towards closing the gap of the most significant health inequalities in our society by having to recognise and consider people facing extreme social exclusion and poor health outcomes in their local areas.
We all know that there will be considerable discussion during the course of this Bill on the need not to be overly prescriptive and burdensome to ICSs and ICPs by way of legal duties. But ICSs and ICPs know all too well the realities of failing to support people with complex and overlapping needs. I know that the chair of my own North Central London ICS, Mike Cooke, is sympathetic to the spirit of these amendments and believes it is important that extra steps are taken to meet the health needs of the most excluded, such as street homeless people. The chief executive of UCLH, David Probert, and the chief executive of Whittington Health, Siobhan Harrington, concur in thinking that if we extend the aspiration to reach out to excluded groups to something that all ICSs, ICPs and systems must focus on, it would be hugely beneficial for planning and joining up systems to avoid inappropriate or unnecessary admissions and poor care planning. Plenty of people want to do this within our health system.
I support Amendments 152, 156 and 157 and look forward to working with the Government and colleagues across the House and within the NHS to ensure their success in achieving a critical and long-needed systemic change to our health and care system. Addressing the needs of the most excluded has to be on the face of the Bill.

Lord Crisp: My Lords, I will make three very practical points about the impact of some of these amendments. First, on tobacco, we have heard from at least two noble Lords that half the difference in life expectancy between the rich and the poor in society is due to tobacco. It seems a no-brainer that work on this has to be continued. I also make the point that it took something like 50 years after the evidence was first available for the control of tobacco to be put into legislation, despite the efforts of the noble Lord, Lord Young of Cookham. It is not a quick win; we need to persevere, keep the pressure on and keep this very firmly in NHS plans at all levels.
Secondly, I want to pick up on the vital point that housing needs to be much more integrated with health and care. Let me take us back in history to 1919 and the first Ministry of Health, which had responsibilities covering health, housing and planning for many years, understanding the very important links there. Covid has shown that a house and home is an absolute foundation for health and well-being in all kinds of  ways. I will not labour that point at this stage in proceedings, but will pick up another that has not come up, which is how important housing is to the provision of NHS services.
Seven years ago, the Royal College of Psychiatrists asked me to look at the reasons for the pressure on admissions to mental health acute wards. I did so; I think it expected me to say that those wards needed more beds, but I came out saying that we needed more housing. I found that something like one-third of the patients in mental health acute wards in adult hospitals either had been admitted because there was nowhere else for them to go or were staying there because there was nowhere for them to live to be discharged to. Housing was the biggest issue. Of the 25 NHS trusts around the country, only about three had specific, strong links with their local housing associations. There is a really big pressure for integration there.
Thirdly and finally, I come to Amendments 152 and 157 about the so-called inclusion health services. I agree with my noble friend on the nomenclature and that the naming is rather awkward, but these are extraordinary vital. We have heard examples of services that work; the issue here is how we can make sure that those services are spread and used elsewhere. I remind the House that, when we talk about inequalities, we all, including me, talk in fairly general terms. If you have a quantum of money and invest it in the health of the well-educated middle classes, you will get a small gain. If you invested that same quantum of money in the needs of this group, you would have a massive gain. That should inspire us to keep the pressure on the Government to make sure that we put tackling inequalities absolutely at the heart of the Bill.

Baroness Walmsley: My Lords, I shall speak more briefly than I had intended, because this has been a very long debate, absolutely full of expertise, about a suite of amendments all of which have considerable merit. I know that both Ministers on the Front Bench have been listening very carefully and have noted the consensus across the Committee that this Bill will not succeed unless it addresses very clearly the disgraceful health inequalities in this country at the moment.
Health inequality affects quality of life, life expectancy and, in particular, healthy life expectancy, which has now stalled across certain demographic groups. As we have heard, it has been analysed brilliantly by Professor Sir Michael Marmot. It affects the well-being of the patient and their family. The really sad thing is that much of it is preventable. These things are particularly rife in the poorer parts of the country, because that is where the social determinants of health such as housing, referred to by my noble friend Lord Shipley and others, have most effect. We have heard a number of statistics about health inequalities, but I shall give your Lordships just one. People living in the most deprived areas of the UK spend almost a third of their lives in poor health, compared to only about a sixth of those living in the least deprived areas. That says it all.
Unfortunately, inequalities were not at the forefront of the Government’s response to the pandemic. They suspended equality impact assessments for legislation,  resisted publication of evidence of the impact of the virus on BAME individuals—as pointed out to them eloquently by the noble Baroness, Lady Lawrence—and failed to provide adequate isolation support for those on low incomes, forcing them to go to work. The Covid pandemic has therefore seen the biggest shift in life expectancy in the UK since World War 2: a fall of 1.2 years in males and 0.9 years in females. It is therefore essential to heed Sir Michael Marmot’s words and “build back fairer” and not just “better”.
The noble Baroness, Lady Greengross, kindly mentioned the report of the Science and Technology Committee on healthy ageing. I was a member of that committee under the capable chairmanship of the noble Lord, Lord Patel. It became very clear from our witnesses that unhealthy ageing happens years before the person is old and depends enormously on their demographic and their lifestyle. For their sake and for the sake of the future of the NHS, for which no Government will ever be able to provide enough funding unless something is done on prevention, we must do something to level up the health outcomes of the nation. This Bill is a very good place to start all over again on that agenda.
I have added my name to Amendment 11, so ably introduced by the noble Baroness, Lady Thornton, whom I must congratulate on the way she analysed these issues at the beginning of this debate. I thank her for that. Also crucial is Amendment 14, so ably promoted by the noble Lord, Lord Patel, and my noble friend Lady Tyler. Amendment 11 is an attempt to ensure that NHS England produces guidance about the collection, analysis, reporting and publication of the data which makes transparent the performance of various NHS bodies on health inequalities. Without collecting that, we cannot judge the performance of those organisations. If it is not done consistently, we cannot assess an organisation’s performance in comparison to other similar bodies. That is why such guidance must come from the top. I know that the Government want each ICS to do its own thing in a way which it considers most appropriate for its area. However, for the important objective of levelling up health outcomes across the population, judgment of performance can be made only if the data is comparable between one ICS and another or one trust and another, so we cannot leave it to them to collect the data in any way they like.
Of course, there are big issues about the resources available for the collection and analysis of data, but such information is essential if improvements are to be made. Therefore, a duty to “have regard” to guidance published by NHSE would put pressure on the organisations to so arrange their finances as to ensure adequate resources for this, and, of course, it would be cost-effective.
I also have Amendments 61 and 63 in this group. They would insert “assess and” into new Section 14Z35 inserted by Clause 20, which covers the duty of an integrated care board to reduce inequalities in access to health services across its population and in the health outcomes achieved. Although it is well known that, in general, the lower the demographic the greater the health inequalities, this is by no means uniform, even across a single local authority, let alone across a  large ICS area. Indeed, even within a single local government ward, which may be fairly affluent in general, there are often pockets of deprivation. Every local councillor knows where they are. In order to devise policies and deploy services geographically in a way that improves access and outcomes for those deprived communities, the ICS needs to drill down and do the detailed work to identify where they are and what factors are damaging health. It may be poor or overcrowded housing. It may be lack of access to shops selling healthy food. It may be lack of access to leisure and sports facilities in which to take exercise. It may be poorly performing schools or overstretched primary care services. It may simply be poverty, preventing people heating their homes adequately or buying nutritious food. In rural areas, it may be lack of access to pretty well everything, as the right reverend Prelate reminded us. Whatever it is, you cannot fix it until you know what and where it is.
That is one of the reasons why we reject the new power of the Secretary of State to meddle in the reconfiguration of health services locally, but that is a debate for another time. In cases such as this, an overview will not do, and local knowledge is key. That is why we believe it is essential to mandate an ICB to do the detailed research on which to base its commissioning decisions, so that it can fulfil the duty to reduce health inequality put on it by this Bill—once it has been amended by a lot of these amendments.

Lord Kamall: My Lords—

Noble Lords: Hear, hear.

Lord Kamall: You have not heard what I am going to say yet.
I thank all noble Lords who have taken part in this debate; it has been fascinating. It has touched on a number of things that I feel strongly about personally. Before we go further, and given my background and that of my right honourable friend the Secretary of State, I want to assure noble Lords that we both feel very strongly about inequalities. I say that as someone who grew up in a working-class immigrant community. I was born at Whittington Hospital; I also accessed North Middlesex hospital and Chase Farm Hospital, with which I know the noble Baroness, Lady Tyler, is associated, though I am not sure I will get any more points for that, to be honest.
One thing I feel strongly about, and saw in many areas when I was an MEP for London, is where the state has failed, whichever Government was in power. I have worked with non-state, local community, bottom-up projects which understood the issues in their communities far better than any national or local politician—there was sometimes even a distance between them and their local ward councillor, as the noble Lord, Lord Mawson, and I were discussing the other day.
I thank the noble Baroness, Lady Thornton, not only for the thoughtful way in which she opened the debate and introduced the amendments but for pointing out some of the people who are often forgotten; for example, the homeless. I have worked with a number of local community homeless projects, such as the  Hope Foundation in Acton and Vision Care for Homeless People. Perhaps I may also do a quick advert for the Take One, Leave One project, which is based outside Vauxhall station on Fridays, between 12 pm and 3 pm —people can leave excess clothes and homeless people can pick them up. I urge any noble Lords passing through Vauxhall station on a Friday to support this.
Sex workers, the Traveller community and drug users have been mentioned. Sometimes we think that these issues are remote from us and will not affect us—but everyone is only one of two steps away from homelessness. A broken family, mental health issues, your friends saying, after a while, “Actually, you can’t stay on my sofa any more”—where do you go? When I have met homeless people, they have quite often come from a very different place, not the stereotype that we often hear. They have come from quite a stable family, a good relationship, a good job: but two or three things have gone wrong in their life and suddenly they are homeless. It happens to many people who resort to such desperate measures.
Another thing I am slightly concerned about, if I am honest, is that when I was a young child growing up in immigrant communities, there was a distrust of authority. We see the difficulty, for example with the vaccine schemes, in trying to reach some of those communities. It was not only authority that we were quite suspicious of and concerned about but—I hope noble Lords will forgive me for using this phrase—white, middle-class do-gooders who thought they knew best what was best for us as working-class immigrant people and could tell us what was best for us, rather than listening to us and our real concerns. Quite often we felt that they had captured the agenda, and that was why the money and resources which were supposed to be helping us did not reach the people who needed help: it got captured by the white, middle-class do-gooders.
I pay tribute to the noble Lord, Lord Howarth, and the noble Baronesses, Lady Greengross and Lady McIntosh of Hudnall, for the emphasis on the arts and creative industries. Sometimes, music and the arts are a way of overcoming this distrust, learning about the culture of those communities and also aligning the culture and the issues with some of the very real problems and tensions we face. The noble Lord, Lord Desai, talked about prevention being better than cure. It is an issue we talk about constantly in the department, and the NHS also talks about it. The noble Lord, Lord Desai, as an economist, will acknowledge that economics is often simply about the allocation of scarce resources and finding the most efficient way of achieving that.
My late father once told me, “Never forget where you came from and what you were”, and this is one of the reasons I feel very strongly, as do many noble Lords across the Committee, about the issue of inequalities. How do we tackle this, what is the best way to do it? Will putting it in the Bill solve all the problems? Actually, it will not, but we can discuss how we can make it more effective, and not just feel, “Great, we’ve got it in the Bill, job done”. It has to be more than that. As the noble Lord, Lord Scriven, said, it cannot just be an institutionalised Gladys; it has to be more than that. So, I am deeply grateful that we gave this issue the time it deserves. It is really important  for me personally. We want to tackle health inequalities and ensure that everyone has the same opportunity to enjoy a long and healthy life, whoever they are, wherever they live and whatever their background or social circumstances.
I hope I can assure the noble Baroness, Lady Greengross, with whom I have had a number of conversations about music and dementia. I have volunteered, perhaps rather rashly, to organise a fundraiser with my band and other bands for that. I hope that does not give me an excuse to lay the YouTube link to my band in the Library: I shall try to avoid that temptation.
However, to deliver on the commitment on 1 October, we launched the Office of Health Improvement and Disparities within the Department of Health and Social Care—the noble Lord, Lord Scriven, anticipated that I would say this—and we also set up a cross-government ministerial group to identify and tackle the wider determinants of poor health and health disparities. It is important that this cannot be top-down; we have to go to some of the social enterprises and local communities, but also we must not prejudge, prevent or duplicate the work of the integrated care systems in this. NHS England is already tackling health disparities through the NHS long-term plan. That sets out a clear intention to set measurable goals and to make differential allocations targeted at reducing health inequalities and disparities. This has resulted in funding increases to some of the most deprived parts of the country.
As we know, making sure that these deprived areas get the most funding does not mean it will trickle down to those who really need it; it could well be captured by some of the do-gooders I mentioned earlier. The noble Lord, Lord Howarth, talked about those targeted interventions. NHS England and NHS Improvement is also taking forward the Core20PLUS5 initiative as an approach to addressing health inequalities. This will focus on improving outcomes in the poorest 20% of the population, along with inclusion health groups and five priority clinical focus areas.
I shall now turn, if noble Lords will allow me, to Amendments 14, 94, 186 and 195. I am grateful to the noble Baronesses, Lady Thornton and Lady Tyler, and the noble Lord, Lord Patel. I hope I can reassure them that much of what they ask for is in the Bill. First, NHS England and integrated care boards have a duty with respect to health inequalities. The duty requires them to have regard to health inequalities in both access and outcomes for patients in the provision of health services. NHS England and the ICBs will have regard to this duty alongside the triple aim and, in NHS England’s case, when it produces guidance on the triple aim. NHS trusts and foundation trusts will, along with the ICBs with which they partner, have to prepare a joint forward plan each year, which will include plans for discharging the ICBs’ health inequalities duty.
The noble Lords, Lord Kakkar and Lord Shipley, and the noble Baroness, Lady Harding, talked about the triple aim. This triple aim is directly conducive to addressing health inequalities. Having organisations consider the wider effect of their decisions will encourage  more collaboration and engagement with communities on how best to meet their needs. For example, the aim of
“considering the health and well-being of the people of England”
means we have to look at those populations with the greatest levels of need, including those not currently accessing services. Indeed, when you ask how an ICB is reaching this aim, the obvious question is, “What about inequalities? Are you just reaching part of the population or the whole population?” So, I assure noble Lords that it really is implicit.
Similarly, it is a key aspect of improving the quality of services to consider those areas within the ICB or the ICS area where they need improvement. You cannot just say “Everything’s great in the richer areas and we’ve considered the wider population”. We mean the wider population, all the population, wherever they come from, whatever their background and whatever their wealth level. To support this, we expect guidance from NHS England to make it clear how bodies can discharge the triple aim duty in such a way as to address inequalities.
I now turn to Amendment 11, in the names of the noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley. This places a statutory duty on NHS England to publish guidance about the collection, analysis, reporting and publication of performance factors by relevant NHS bodies with respect to inequalities. We agree that collection of accurate and timely data is an essential part of the department’s commitment to tackle health disparities in terms of planning, goal setting and the use of evidence-based interventions. As my noble friend Lord Bethell said, seeing that data made real to him and others the fact that there were these disparities, and it is important that we continue collecting it. However, we feel that collection of data on disparities and protected characteristics can be best achieved through operational guidance. We want to offer flexibility for the system to adapt the focus and methods of that data collection and analysis, and the power to do that is in the Bill.
We will continue to work with counterparts in the NHS and other system partners to make sure that this data is adequately identified, reported and assessed, and which further amendments, if any, will be required for the ongoing work. High-quality data is fundamental to our approach to reducing the stark disparities in health that exist in the country. If any policy changes are identified which require legislation, we do not rule out bringing them forward.
I turn now to Amendments 61 and 63, for which I thank the noble Baroness, Lady Walmsley. These amendments would add to the duties currently in the Bill on ICBs with regards to health inequalities. I hope I can reassure the Committee that we feel that this is already done. As members of local health and well-being boards—place-based, not just at the ICS level but at the place, as the noble Lord, Lord Mawson, talked about so eloquently—ICBs will be closely involved in the development of local joint strategic needs assessments, which are the means by which local leaders work together to assess and understand the needs of local people. We are concerned that it might duplicate this effort if an entirely separate assessment were to be  made of one aspect of local needs. Perhaps we could look at ways to draw out this particular aspect so there is no duplication. Furthermore, it is our view that ICBs could not effectively discharge their duties in respect of inequalities if they did not identify the inequalities they are seeking to address, making use of the most up to date evidence and data available and learning from each other what data is collected. Is the data collected in a local ICS really giving a better picture as compared with elsewhere?
To help the process, NHS England has published a range of tools and resources to help NHS organisations to take effective action on inequalities, and continues to develop a health inequalities improvement dashboard, making sure that we learn from that data so that we monitor, measure and inform actionable insight to make improvements to narrow those health inequalities. It covers the five priority areas for narrowing health inequalities in the 2021-22 planning guidance, as well as the Core20PLUS5 programme.
I turn now to Amendment 65, in the names of the noble Lord, Lord Patel, and the noble Baroness, Lady Tyler, which would add a further explicit duty to implement systems to identify and monitor inequalities. It is the Government’s view that the ICBs could not effectively discharge the duties already contained in the Bill in respect of inequalities if they did not already do so; nor could they have any confidence that the actions they take are being effective if they do not monitor the outcomes achieved. You simply cannot do it if you are not monitoring. Furthermore, ICBs will have a duty to publish an annual joint forward plan setting out, among other things, how the ICB will discharge its duty in respect of reducing inequalities. Again, this could not be effectively done without having first identified those inequalities. Taken together, I hope the noble Lords might agree that this meets the intention of their amendment.
I turn to Amendment 66, in the name of the noble Lord, Lord Young, and spoken to so eloquently by the noble Lords, Lord Rennard, Lord Faulkner and Lord Crisp. This amendment would expand the duty on ICBs to have regard to the need to reduce inequalities to include modifiable risk factors such as smoking. We do not feel that this amendment is necessary, given the considerable work we are already doing in this area. We have reduced smoking rates in England over the years to a record low of 13.5% in quarter 1 of 2020, and we are aiming for England to be smoke-free by 2030. In a previous debate, in answer to a question about the plan asked by my noble friend Lord Young, we also identified those areas. Indeed, the noble Lord, Lord Rennard, referred to some of the statistics on the high levels of smoking still prevalent in some of our poorer communities. Our publication of a new tobacco control plan next year will include an even sharper focus on that issue.
We are also investing £27 million to establish specialist alcohol care teams in the 25% of hospitals with the highest rates of alcohol dependence-related admissions. We really have not, as a society, properly got to the stage where alcohol is seen as a social tool that loosens tongues and may make people relax, but the step from alcohol doing all those things to relax people to its abuse has a terrible impact on people’s lives. Moreover,  it not only has direct health impacts but plays a role in murders, suicides, drownings and so on. We have to recognise what alcohol does as a drug and its terrible impact.
We also have an extensive strategy for tackling obesity, including some of the measures already debated on less healthy food and drink that are being introduced via the Bill. We are concerned that introducing an amendment as specific as this may not be the most effective way to prioritise actions to meet local population needs, a phrase so eloquently used by the noble Baroness, Lady Neuberger.
I turn next to Amendments 68 and 95, in the name of the right reverend Prelate the Bishop of St Albans. The Government are determined to address long-standing health disparities, including the geographic disparities experienced in rural and coastal communities. I pay tribute to my noble friend Lady McIntosh of Pickering and the noble Baroness, Lady Pitkeathley, who have constantly raised the issues of inequality of health outcomes in rural and coastal areas and how people there access services. For that purpose, the Bill already contains a requirement for the commissioning bodies to tackle these health inequalities, as well as a requirement to protect, promote and facilitate the rights of patients. This means allowing patients to choose to be treated outside their ICB area, particularly if that makes more sense, as alluded to by the right reverend Prelate. To support this, we expect ICBs to actively co-operate with each other for tackling these inequalities. We understand the duty to reduce inequalities to also encompass the need to reduce inequalities between patients with respect to geographical locations, such as rural or coastal areas. The proposed triple aim will also require ICBs to consider the quality of services that can be accessed both in communities but also geographically. I hope I have given the right reverend Prelate the Bishop of St Albans some reassurance on this.
Moving on, I turn to Amendments 152 and 157, in the names of my noble friend Lord Young and the noble Lord, Lord Shipley. These amendments would require the ICP to have regard to the needs of inclusion health populations. A number of noble Lords have spoken about the sort of clumsiness of that title of “inclusion health”. While we agree with the sentiment, I hope I can assure the noble Lords that these populations are already captured in the legislation. As noble Lords will be aware, the integrated care partnership will be tasked with developing a joint strategy to address the health, social care and public health needs of its system, based on the needs identified by the already-existing health and well-being boards, which are better placed to tackle these issues. The joint strategic needs assessments include the health needs of these populations, and those who need to be included more. The strategy prepared by the ICPs to address this will enable them to objectively identify what the inequalities are and target them. The ICP will be tasked with promoting the partnership arrangements. We hope that this will remove some of the traditional divisions between different healthcare services and between the NHS and local authority services.
I would like to touch on some of the work already ongoing in this area. For example, this year alone we delivered £52 million for substance misuse treatment  services for people sleeping rough. This will fund evidence-based treatment. One of the criticisms of public health sometimes is that there is not enough evidence-based research, and it is essential that we have it. We will look at treatment and wraparound support for those with co-occurring mental health needs.
Let me turn, finally, to Amendment 156 in the names of my noble friend Lord Young and the noble Lord, Lord Shipley, and spoken to by the noble Baroness, Lady Watkins. It relates to the integrated care strategy, and how the ICP will be required to set out how the assessed needs in its area will be met. We recognise that health inequalities are driven by a range of complex factors. The noble Baronesses, Lady Watkins and Lady Finlay, and my noble friend Lord Bethell said this. These complex factors go way beyond people’s physical and mental health, and touch on some of the wider economic and societal issues, such as the one the noble Lords raise in this amendment. The Bill already ensures that services that have an effect on health, but are not health or social care services, are included in the clause that the noble Lords seek to amend. Even without this amendment, ICPs will be able to comment on whether housing services—which the noble Lord, Lord Crisp, raised—among other health-related services, will need to be better integrated with the provision of health and social care.
This has been an excellent and—I accept—long debate, as the noble Baroness, Lady Walmsley, said. It was probably one of the issues that I was most looking forward to learning and hearing more about. I was impressed by the level of commitment and the passion with which noble Lords spoke. I hope I have been able to give some measure of assurance that the Government take this issue extremely seriously. As I said at the beginning, both my right honourable friend, the Secretary of State and I, given our personal backgrounds, feel very strongly about this. We do not want it this to be captured once again, as it has been captured over many years, by the do-gooders.
I request that noble Lords do not press their amendments but, given the strength of the feeling that I have heard, it would be remiss of me not to offer further discussions with noble Lords so that we can close the gap in the understanding—as the noble Lord, Lord Kakkar, and my noble friend Lady Harding said—that it cannot be too NHS-centric. We have to work out how to address that gap. We think the Bill meets it; clearly, noble Lords across the Committee feel that it does not. Let us have further conversations. I hope noble Lords feel able, in that spirit, to withdraw or not move their amendments at this stage.

Baroness Walmsley: My Lords, I thank the Minister for his very able response, but I have to say that I am very disappointed by it. He appears to be sticking to his brief and resisting all of our amendments. I suppose this is not surprising because his brief was written before this very powerful debate. Now that he has heard the debate, I hope he will go back to the department, discuss with his colleagues, and reflect on the need to put something in the Bill to ensure that the new world of integrated care systems really addresses health inequalities.

Baroness Thornton: Hear, hear to that. As I stand in your Lordships’ House, I know that I am between noble Lords and their lunch, so I will do my best to be as quick as I can. I also feel that I need to declare an interest, as I am a non-executive director of the Whittington Trust, so my boss—the noble Baroness, Lady Neuberger—is in the corner over there.
I start by thanking the noble Lords, Lord Patel and Lord Kakkar, and the noble Baronesses, Lady Walmsley and Lady Tyler, for adding their names to and being part of this suite of amendments that I have been particularly concerned with. I am not quite sure which one of them said this—it was probably the noble Lord, Lord Kakkar—but Amendment 11 sets the national framework, and the following very short amendments which add inequalities into the Bill are about making sure that the local delivery actually happens.
I thank my noble friends Lord Howarth and Lady McIntosh for their remarks, which wonderfully illustrated how important it is to take—I hate this word—a holistic approach to health inequalities and well-being. I also congratulate and thank the noble Lords, Lord Young, Lord Rennard and Lord Crisp, and my noble friend Lord Faulkner, for again drawing the House’s attention to the importance and centrality of tobacco regulation to delivering health equalities. They were quite right about inclusion health services.
I also thank the right reverend Prelate the Bishop of Carlisle and the noble Baroness, Lady Walmsley, for speaking to the amendments about monitoring. Those of us who have been involved in dealing with equalities for the whole of our working lives know that if you do not monitor, assess and count, you will not know what effect you are having. Amendment 65 particularly recognises that, and that monitoring is vital to tackling inequalities. The noble Baroness, Lady Watkins, supported the need to address the needs of the most marginalised, and she was right that flexibility and the values of social enterprise are a part of tackling health inequalities at a local level. The right reverend Prelate the Bishop of St Albans and my noble friend Lady Pitkeathley were quite correct to draw rural areas and their needs to the attention of the House.
I think I need to thank the noble Baroness, Lady Harding, and the noble Lord, Lord Bethell, for their support for these amendments. I hope that they will bring their influence to bear on the Government to accept that there is a gap between the Bill as drafted and what the House wants to see in it.
I am not going to say very much more, but I was not convinced by the reasons for not accepting Amendment 11 and the other amendments in this group, and I think that other noble Lords will not be. I think the Minister can recognise when the House is determined to have on the face of a Bill something which addresses a wrong that they feel should be righted. We know—as I think the noble Lord, Lord Scriven, said—that words do not actually deliver the change, but words are the place where you have to start to deliver the change with inequalities. You have to see what is in the Bill and then move to implement that. There is a gap between us, but I hope—I am very encouraged by  the noble Lord’s commitment to discussions—that we will be able to address it. I beg leave to withdraw my amendment.
Amendment 11 withdrawn.
Amendment 12 not moved.
Clause 3 agreed.
Clause 4 agreed.

  
Clause 5: NHS England: wider effect of decisions
  

Amendments 13 and 14 not moved.
House resumed. Committee to begin again at a convenient point after 3.34 pm.

Taking Control of Goods (Fees) (Amendment) Regulations 2021
 - Motion to Regret

Baroness Meacher: Moved by Baroness Meacher
That this House regrets that the Taking Control of Goods (Fees) (Amendment) Regulations 2021 (SI 2021/1288), laid before the House on 18 November 2021, fail to deal with the injustice to debtors from 2014 to the date guidance on the new Regulations took effect.

Baroness Meacher: My Lords, I rise to move my Motion to Regret Statutory Instrument 1288—enforced in England and Wales—on taking control of goods. Today’s debate provides an opportunity to highlight the fact that since 2014, debtors have been wrongly charged VAT on the enforcement of debt repayments, when the tax should have been charged, of course, to the creditors involved. Enforcement officers are providing a service to creditors and—believe me—not to debtors.
The VAT chargeable is upon the service to creditors, and it is those creditors who should have paid. This issue and the inaction over seven years by both government and industry to clarify the situation was drawn to my attention by the organisation Just and the debt advice services. They focused on the impact of the incorrect charges on the most vulnerable in society and the injustice involved.
I emphasise at the start that the failure to sort out this injustice over the years was principally the responsibility of previous Ministers and industry. We are grateful that the Government are finally issuing this SI, which will ensure that the injustice does not continue into the future. The reason for this Motion to Regret is the failure of this SI to deal with seven years of injustice from 2014 to 2021, which has resulted in millions of pounds of incorrect charging. This debate provides an opportunity for the Minister to clarify steps that will be taken to resolve the VAT payment injustice once and for all and to ensure that debtors are repaid where they were incorrectly charged.
Before setting out why we believe the Government must take action on these misdirected demands, I want to explain why this injustice is so serious. Of course, the link between debt problems and mental health is well established. The Money and Mental Health Policy Institute estimates that people with money problems are three times more likely to commit suicide than those without debts. The stress associated with debt is a major contributor to depression and other mental health symptoms. Additionally, money issues often affect entire households, so parents, children, family members and friends are impacted by the damaging effects of debt, not just one individual.
Given that this Government have made protecting the vulnerable one of their primary objectives and so much work has been done by our society over the past few years to make mental health a more mainstream issue that people should take seriously, helping those with money issues should be an absolute priority. Given the cost-of-living crisis in the UK at the moment, it has arguably never been a more important time to discuss these issues.
Let me outline what has been going on. In the High Court enforcement sector, judgment debts for things such as unpaid utility bills are charged to debtors: the person in debt. The creditor—the company owed money —will employ a High Court enforcement officer to recover this money. This officer will ensure that the debtor pays the money owed and will charge the debtor fees for the enforcement action taken. That is not unreasonable, you would think. On top of these fees, High Court enforcement officers will charge VAT. This in itself is not an issue, as in 90% to 95% of cases the officers act on behalf of VAT-registered debt enforcement companies. But, as I have said, this VAT should be charged to the creditor, who can recover the VAT incurred from HMRC if the company is VAT registered.
However, since 2014, the regulations have been misinterpreted by industry and, if I may say so, have been unclear. Instead of charging the VAT or a VAT-equivalent fee to the creditors, this money has been charged to the debtors, as I have said. This means that the debtors, who are already financially vulnerable and face hefty fees—often unreasonably hefty fees, I should say—on top of their debts have also wrongly been charged hundreds of additional pounds. Industry estimates that about £120 million may have been taken incorrectly from vulnerable debtors. That is over £1 million a month—a lot of money from very vulnerable people.
This practice is clearly absolutely unacceptable; how has it been going on for seven years? It is clear from documents publicly available online that the High Court Enforcement Officers Association—the membership body that represents these officers and is authorised by the Ministry of Justice—raised this issue with the ministry as early as 2015, yet no action was taken either by industry or by government. Of course, that is the fault not of current Ministers but certainly of previous ones. I want to make clear that the noble Lord, Lord Wolfson, wrote to me and indicated that somehow the ministry had only just heard about this in 2019. In responding, the Minister might accept that 2015 is actually the date when the ministry knew about it.
The High Court Enforcement Officers Association, authorised by the MoJ, sought legal advice from Christopher Wilson QC to clarify the issue. Wilson, in his advice, said, “HMRC recognised in 2000 that debt enforcement was a service to creditors and they should issue VAT invoices only to creditors.” Nevertheless, Wilson’s findings were inconclusive, but his most important recommendation was that the High Court Enforcement Officers Association should take the advice of leading counsel on tax matters on the issue. Again, no further action was taken after this.
Four years went by without anything changing. The issue was never addressed and was kept quiet by both government and industry. For the Government, this was a problem they themselves had created by not providing clear guidance in the regulations. Perhaps Ministers at the time felt that any action was an admission of guilt and to do nothing was probably the safest option. The industry had a strong incentive to let sleeping dogs lie: debt enforcement companies appeared cheaper to creditors because they were not charging VAT on their fees. This made them comparable to a creditor using the Government’s own bailiff services, whereby VAT is not charged. They were benefiting from collecting the extra cash from debtors.
In 2019, a new entrant to the industry, an organisation called Just, sought advice from Melanie Hall QC, a tax specialist. It did this after reviewing the previous advice issued to the High Court Enforcement Officers Association by Christopher Wilson QC—something the association and the MoJ should have done four years earlier. This kick-started the process to resolve the issue. Hall’s guidance was clear that debtors should not be charged VAT or a fee equivalent to it. This guidance provided the opportunity for Just to engage the MoJ and for the Government to provide clarity and thereby correct the situation. After six months of campaigning from Just, parliamentarians and the debt advice sector, the MoJ published draft guidance privately—I emphasise “privately”—to key stakeholders in March 2020, clarifying that debtors should not be charged VAT or an equivalent fee where creditors are not VAT-registered. Although this guidance was not perfect, it resolved 90% to 95% of debt enforcement cases going forward where debtors would otherwise have been charged VAT incorrectly.
This was a momentous step in the right direction, though the guidance was issued only privately. Sadly, this was not the end of the story. It took the MoJ a further 19 months to publish this guidance. Covid-19 undoubtedly had an impact on MoJ resources, but the delay in publishing the guidance meant that more debtors overpaid on their debts, reducing their already depleted and no doubt minimal disposable income and potentially costing them an additional £19 million over those months.
After months of silence from the MoJ, Just decided that action needed to be taken and sought an application for direction from the Royal Courts of Justice. This meant taking the Government to court and allowing the court to clarify whether this practice should continue. The prospect of losing in court galvanised the Government. I want to emphasise this point: just four minutes before the judgment hearing at the Royal Courts of Justice, the MoJ published its guidance and  promised to lay a statutory instrument to clarify the existing regulations. I will leave it to noble Lords to consider whether we would be having this SI had there not been the court case.
That brings us to today. Statutory Instrument 1288 makes clear in Regulation 18(1) that
“where a creditor is VAT registered the enforcement agent may not recover from the debtor VAT or the sum equivalent to VAT on the fees or disbursements.”
I want to clarify that I warmly welcome the clarity provided by this statutory instrument. As I said, my reason for tabling a Motion to Regret to this SI concerns the failure of this crucial document to address the injustices of the past seven years. It is silent on the need for those who have been wrongly charged VAT on the activities of enforcement officers to be repaid. Surely, they should be.
This is especially important because the statute of limitations outlines that there is only a six-year window in which debtors could rightfully claim for this money to be returned to them. This inaction means that, sadly, for some debtors, it is already too late to get their money back. I want these vulnerable people to know that parliamentarians are aware of the injustice they have suffered. Even more importantly, I want to make sure that Ministers have considered what action they should take to ensure repayment of the money wrongly paid by debtors over the past seven years. I have already emphasised the importance of this money to the most vulnerable indebted families. A few hundred pounds could make the difference for someone’s children to eat three meals a day for the rest of the month or for a family to heat their home over the winter months. The sort of sums we are talking about can be really crucial for them. It may not be crucial to any of us, but for these families it really is.
I am not here today to frustrate the progress of this SI; the clarity it provides for the future is precious. But today is an opportunity to highlight what the Government need to do to ensure that debtors get their money back. I wrote to the noble Lord, Lord Wolfson of Tredegar, on 10 December, setting out the actions we believe the Government need to take, alongside the approval of SI 1288, to address the injustices of the past seven years. They are as follows. First, the Ministry of Justice should issue guidance to the High Court Enforcement Officers Association, advising it to write to all debtors who have been overcharged and inform them. At the very least, it is vital to make sure that debtors are made aware they may have overpaid. Secondly, the Ministry of Justice should conduct a full impact assessment to calculate the amount of VAT wrongly charged to debtors by the debt enforcement industry. In their Explanatory Note to the SI, the Government admitted that they had not conducted any such impact assessment. We need to know how much money is owed here. Thirdly, the Ministry of Justice should advise the High Court Enforcement Officers Association to set up a compensation fund for debtors. While the MoJ does not have the legal authority to force businesses to give back money they owe, showing leadership and using governmental influence to advise industry to voluntarily set up its own compensation arrangements is nevertheless surely the right thing to do.
It should not be up to debtors to seek a resolution through group litigation. Debt enforcement is probably something they could not possibly do in their situation. The debt enforcement companies should do what is right. I believe that if the Government ensure that all debtors are informed if they have been overcharged, and if the Government assess how much has been wrongfully overcharged to debtors, it brings everything into the public domain and repayment becomes more likely. These measures can be taken side by side with this SI and without statutory underpinning. I have outlined the historical issue, the injustice involved and the need for the Government to take actions to ensure that our most vulnerable citizens are repaid the debts owed to them.
I want to thank all the Peers here today in the Chamber today to support the plight of debtors and to ensure that the money they have overpaid is rightfully returned. I also want to thank Peers who are unable to attend the debate but have expressed their strong support for this Motion and action to refund debtors. They include the noble Baronesses, Lady Lister of Burtersett, Lady Burt of Solihull and Lady Stern, and the noble Lords, Lord Stevenson of Balmacara, Lord Laming, Lord Howarth and Lord Dholakia.
I know Ministers care about mental health; today, they have the opportunity to do something concrete to improve the mental health of those in greatest need. I want to thank the noble Lord, Lord Wolfson, for writing to me. It seems the Government are unwilling to make commitments at this stage and want to await the outcome of the litigation. Nevertheless, I look forward to the Minister’s response today.

Lord Thomas of Gresford: My Lords, it is a great pleasure to follow the noble Baroness, Lady Meacher, in her very clear and lengthy exposition of the position. I applaud her efforts and seek to follow in her footsteps.
In his Written Statement on 18 November, the Under-Secretary of State for Justice, James Cartlidge, said:
“While we take the view that the taking control of goods legislation when considered … with the common law position permits the recovery of VAT costs from debtors in this way, we have accepted … that this is an area where it would be beneficial to set out the position in regulations to put the matter beyond doubt.”—[Official Report, Commons, 18/11/21; col. 34WS.]
Well, they have done that, but some questions remain.
In enforcing a debt there are three parties: the judgment creditor, the judgment debtor and the enforcement agent. What this instrument does is permit the enforcement agent to recover from the judgment debtor a sum of money equivalent to VAT on his costs and expenses, even though the judgment creditor is not registered and therefore not liable to collect or account for VAT to the Treasury.
A number of questions arise. First, what if the enforcement agent is himself not registered for VAT? How does he account to the Treasury for a sum equivalent to VAT? Would he not just pocket it? What happens to that money? Secondly, when did the common law take cognisance of VAT? Perhaps the Minister will explain the meaning of Mr Cartlidge’s reference to the “common law position”? I find it difficult to comprehend  why, if the judgment debtor would not have to pay VAT to the judgment creditor, the common law would force him to pay it to the tipstaff on behalf of the bailiff.
Section 90 of the Tribunals, Courts and Enforcement Act 2007 gives power to the Lord Chancellor if he “considers it necessary or expedient” to make
“supplementary, incidental or consequential provision”
or
“transitory, transitional or saving provision”
by regulations. In Schedule 12—on which this instrument also depends—paragraph 13(3) deals with taking control of goods, paragraph 42 with the sale of goods, and paragraphs 50(4) and 50(7) with the application of the proceeds. How is there power to make this instrument, which, in effect, imposes taxation upon the judgment debtor which he would not have to pay if the judgment creditor were registered for VAT? It is arbitrary; it is luck, a matter of chance.
The Minister will appreciate that if you have worked, as I have, as a solicitor in a close mining community in north Wales—not dissimilar to Tredegar, I may say—there is always concern about the activities of bailiffs and their tactics. I include in that claiming fees for visits to the debtor which were never made, or where the knock on the door was particularly soft and a second visit follows. Clients are not aware or made aware of their ability to go to court to tax the bills for their expenses, and these are not inconsiderable sums. If it is council tax, parking fines, or a debt under £1,500, for example, it is £75 for a letter, a £235 fixed fee for a visit to your home and a £110 fixed fee for taking and selling your possessions. Over £1,500, there is an extra fee of 7.5% on each of the latter two stages. A High Court judgment of under £1,500 attracts fixed fees of £190 for a visit, £495 for failing to keep to an enforcement agreement and £525 for taking and selling your belongings. If it is over £1,500, 7.5% is added to the enforcement and sale fees.
We are about to face a period of inflation, high interest rates and a rise in the cost of living. This will be familiar to those of us who are old enough but not to the youngsters raising their families. I hope somebody judicially reviews this instrument because I do not think it is properly made and I very much hope it will come back to haunt what is left of this Government.

Lord Best: My Lords, I support this Motion to Regret in the name of my noble friend Lady Meacher. The last thing needed by those trying to deal with a problem debt is an extra 20% charge on top of the collection costs in tax that should clearly have been levied on the creditors, not the debtors. It is surely a great injustice for debtors to have been charged VAT when they should not have been and to have to go to considerable lengths to recover money they have been falsely charged. It is certainly a matter of deep regret and the remedies proposed by my noble friend seem entirely justified.
Perhaps I could take this opportunity, on the subject of bailiffs, to note that there is considerable political and practitioner interest in bailiff reform. Will the Minister reaffirm the Government’s support for the enforcement conduct authority as organised by the Centre for Social Justice in partnership with both the bailiff  sector and the debt advice sector? Impressive work has been done by the CSJ in securing agreement between those representing bailiffs and those providing debt advice, such as the charity StepChange. This now needs government to take matters forward and grant statutory powers to this new body to give it real teeth. Perhaps the Minister could comment.

Lord McNicol of West Kilbride: My Lords, I declare an interest. A close family member was supported by StepChange, and to say that its engagement and support were life-changing is an understatement.
This is an issue which has united parliamentarians from across both Houses and both sides of the House, as well as the advice sector. It is right that the matter is before us, and I thank the noble Baroness, Lady Meacher, for giving us the opportunity to consider it today. I also join her in thanking Just for its briefing and, probably more importantly, for its campaigning on this issue. As she rightly said, I am not sure we would be here today if Just had not taken it as far as it had.
As we have heard, enforcement officers have been incorrectly charging VAT to debtors since 2014. The Government, I think, agree that debtors should not be paying the VAT and Ministers have confirmed this at the Dispatch Box previously. When the matter was raised in Parliament by my noble friend Lord Stevenson of Balmacara in 2019, the noble Earl, Lord Courtown, said on behalf of the Treasury that
“any VAT due is payable by the creditor who receives the service. The debtor is not required to pay the VAT.”
As Parliamentary Answers go, that is quite unequivocal. That should have instigated an immediate reset of VAT charging at that point. It would have been nice if the MoJ had listened to the Treasury then.
The SI deals with the charging of VAT and ensures that, going forward, High Court enforcement officers—HCEOs—do not charge debtors. That is to be welcomed. The move should be to the creditors. Like the noble Baroness, Lady Meacher, we are concerned that the Government are not tackling the historic overcharging that has been taking place for at least the last seven years. The Government accept that debtors have been unfairly taxed, so can the Minister please explain why the Government are not committing to providing—as the noble Baroness, Lady Meacher, has outlined—tax refunds or other systems to resolve this mischarge to debtors? There is an established principle when someone has been financially wronged: we saw it regarding PPI and heard it in the news this morning in a recommendation from the ombudsman about incorrect benefits payments. Why are the Government taking this position?
There may well be another simple solution. I look for a response from the Minister to this. It could possibly be dealt with as an administration task. The MoJ could order debt enforcement companies to return the VAT to the debtors who had overpaid it. The debt enforcement companies which are VAT registered would then reinvoice the creditors to return this money to them. The creditors could submit this VAT as a cost to HMRC. This means it would not cost the debt enforcement companies or the creditors any money. It would be a return through the VAT system directly from HMRC. I look forward to the Minister’s response.

Baroness Boycott: My Lords, what we have here is a very serious issue. We already know that, since 2014, debtors have been incorrectly charged VAT when it has been ruled that this should instead be charged to the creditor. Although the Ministry of Justice clarified in its March 2020 and November 2021 guidance that if the creditor is VAT-registered, debtors should not be charged VAT, it did not clarify the actions it would take to look into giving the money back. For this reason alone, I am supportive of the Motion in the name of the noble Baroness, Lady Meacher, to regret the taking control of goods statutory instrument.
Also, to put it simply, time is running out. Some noble Lords may be aware, but many will not, that there is only a six-year window in which debtors can rightfully claim for this money to be repaid. This means that many debtors, many of whom will not even be aware that this money belongs to them, have unjustly missed out on their opportunity to reclaim VAT. Therefore, the time for action is now. With every passing day of delay, more and more debtors will continue to miss out.
We have come out of a busy Christmas period, the time when many families’ budgets become overly stretched and more financially challenging. The truth is that it is expensive to be poor in this country at the moment. For the average poor family, the poverty premium—a horrible expression—means £490 extra to pay because of meters, being unable to buy in bulk and paying individually for things that other people could pay for in excess. For one in 10 people, that poverty premium is £780 a year. Will the Government ensure that the debt enforcement sector notifies all debtors who may have overpaid VAT? Will they conduct an impact assessment to understand exactly how much has been overpaid? Finally, will they ensure that the debt enforcement sector sets up a scheme to refund this money?

Lord Wolfson of Tredegar: My Lords, I am grateful to all noble Lords who have contributed to this debate, in particular the noble Baroness, Lady Meacher, whose Motion gave rise to it. The Motion highlights concern about whether debtors have been overcharged in respect of the VAT that attaches to the fees charged by High Court enforcement officers.
The statutory instrument before the House sets out how the VAT that attaches to enforcement agent fees should be collected. The burden of the noble Baroness’s Motion is to criticise the Government for not going further by applying that retrospectively. A number of noble Lords asked what we propose to do to provide compensation to debtors who were charged VAT wrongly prior to the date on which the instrument took effect. I will seek to explain why the use of “wrongly” is itself subject to question.
Let me set out the purpose of the SI and why we have decided that it is necessary to provide clarity and explain why it would not be possible or fair to legislate retrospectively in this area. We decided that it was necessary to legislate because in the summer of 2019—I accept that the issue was floating around earlier—we  were made aware that there were dramatically diverging views and practices within the High Court enforcement industry about who the VAT on its fees should be collected from. We initially sought to provide clarity by working with HMRC to draft guidance about the correct approach.
With apologies to the House, I would point out gently to the noble Lord, Lord Thomas of Gresford, that we must be careful when we talk about collecting VAT. There are two different issues here. The first is who is responsible for paying the VAT. The second is can you, as the creditor, recover through the enforcement agent a sum equivalent to the VAT. When the debtor pays that sum, the debtor is are not paying VAT; the debtor is paying a sum equivalent to VAT. That sounds like a legal technicality, but it is not; it is a fundamental distinction that it at the heart of this issue.
An important point to make is that neither the guidance nor the SI seeks to change underlying VAT law. In all circumstances, the creditor is liable for the VAT. That is because the creditor is the recipient of the service of the High Court enforcement officer. The guidance and the SI set out the circumstances in which a sum equivalent to the VAT charged to the creditor can be recovered from the judgment debtor as an enforcement cost. We designed that guidance to ensure careful and fair operation of the law so that creditors would not be out of pocket as a result of enforcement costs, while also ensuring that an amount equivalent to VAT was collected from debtors only in cases where the VAT represented a real cost to the creditor. In other words, an amount equivalent to VAT would be collected from the debtor only in cases where the creditor was not able to recover the VAT from HMRC as an input tax. If the creditor was able to recover the VAT from HMRC, the VAT would not be a real cost to the creditor and therefore a sum equivalent to the VAT should not be collected from the debtor.
In March 2020, we consulted interested parties about the draft guidance. Views remained mixed about whether VAT should ever be recovered from the debtor because the debtor was not the recipient of the service. We considered then, as we do now, that it is fair for the creditor to be able to recover the VAT as an enforcement cost in cases where it will represent a real cost to the creditor. That approach is in keeping with the overarching principle that the debtor is responsible for the costs of enforcement. Some consultees questioned the legal basis for our draft guidance. They noted that the regulations setting out the fees that High Court enforcement agents can recover from debtors do not refer to VAT, so we have accepted that it would be helpful to set out the position in legislation to put the matter beyond doubt. That is what this SI seeks to do.
We have listened to the feedback that we received about the draft guidance and taken on board the dangers that a system that is too complicated or nuanced will make it even more difficult for a debtor to understand whether they were paying the correct enforcement costs and, as a consequence, to know whether to challenge an account of the charges they are presented with. The feedback also highlighted how, in a very complicated system to address this issue, more mistakes are likely to be made.
We do not want that to happen. We want to try to have a simple and comprehensible but fair system. We therefore decided that this SI should allow an amount equivalent to the VAT to be recovered from the judgment debtor only in cases where the creditor is not VAT-registered and cannot therefore recover the VAT from HMRC. We think that approach is simple and properly supportable in principle. We think that it is right to allow creditors in those circumstances, although only those who are not VAT-registered, to recover an amount equivalent to the VAT from debtors as it would represent to them a cost of enforcement. We must remember that the creditors may themselves be suffering from financial vulnerability. For example, the creditor may be an individual who has lost their job, sued their employer and got an award of damages for wages. If we do not have this regulation, it is the creditor who will be out of pocket because they will have to pay the costs of enforcement. So I say with great respect that we cannot approach this matter a little simplistically by assuming that the debtor is always the small person, so to speak, and the creditor is always the grasping outfit. That is not the case.
We must also remember that under this SI an amount equivalent to VAT will not be recovered from the debtor in the vast majority of cases as most creditors will be VAT-registered. I should acknowledge that, as we set out in the Explanatory Memorandum, some VAT-registered creditors may make both taxable and exempt supplies. They will be able to recover only a proportion of the total VAT from HMRC. However, we think that putting them together with VAT-registered creditors is the appropriate policy option. We therefore think that this SI strikes the right balance to ensure that an amount equivalent to VAT is recovered from debtors only where it represents a real cost to the creditor.
I accept that we could have acted faster to clarify this matter. We consulted on draft guidance in March 2020. The work to finalise that guidance was delayed as a result of the department’s response to the pandemic. For example, in this area, we diverted resources and introduced legislative bans on enforcement action by enforcement agents in order to protect public health, so the coronavirus pandemic had an impact on this area as well.
I certainly do not want disagreements about what should have happened in the past to delay any further clarification of future practice, so I am grateful to the noble Baroness for amending the Motion to one of regret.
I understand the concerns expressed about whether in the past debtors have paid more than they should have done. I have great sympathy for the wish, expressed by a number of speakers, to ensure that debtors can have their concerns addressed in legislation. However, limits on retrospective legislation are an important safeguard in a just society as well as being a principle of the rule of law. There must be strong reasons to test those limits even where there is the power to do so. This issue is not one of those exceptional cases.
The issues raised in the Motion are largely matters of private law as between debtors, enforcement agents and creditors, and the interpretation of the legal position between those private parties is a matter for the courts.  As we have heard, the issue is currently before the High Court in litigation. It is tempting but slightly inaccurate to say that the Government were taken to court, with all that implies. That case is in fact about a declaration being sought from the court as to what the law is. It is fair to say that there are widely divergent opinions on what the correct legal position prior to this SI in fact was.
To pick up the point made by the noble Lord, Lord Thomas of Gresford, the common law position is simply this. My friend in the other place was not saying that the common law imposes VAT but that it is a basic principle of the common law that when you enforce a debt, you can recover the debt and the costs of enforcement of the debt. If VAT is to you a real cost of enforcement, an amount equivalent to that VAT is recoverable from the debtor. That ties in with basic principles of enforcement of debts, whether it is VAT or indeed your solicitor’s costs in bringing the matter to court and enforcement. To pick up another point, if the enforcement agent is not registered for VAT, they cannot charge VAT on their fees, so the point does not arise in the first place.
We do not think it would be appropriate to legislate for the past. I respectfully disagree with the noble Baroness when she assumes that debtors who paid VAT or a sum equivalent to VAT in the past were wrongly overcharged. That is a point of law which is in dispute. However, we think that debtors must pay the costs of enforcement of a judgment debt. At the same time, we want to ensure that debtors are fairly treated, not just in relation to the process of enforcement but to the costs of the process.
I do not want to give the House a history lesson, but if one goes back to the high sheriff and undersheriffs of days gone by, the predecessors of the High Court enforcement officers, there is an interesting analysis of whether VAT would or might have applied to their fees. Were they acting on behalf of the creditor or on behalf of the court? It is not always very easy to analyse.
VAT itself is not an uncomplex system, so it is easy to understand why successive Governments were perhaps less prescriptive than they might have been as to how it would impact on the fee rates. None the less, where VAT imposes an additional sum and that sum cannot be recovered by the creditor as an input tax, it is an enforcement cost and should be recoverable from the debtor. That said, given that the matter is seized by the High Court, obviously we will keep a close eye on that litigation. We will look at any findings of the court extremely carefully and will consider whether any further action in this area is necessary.
Before I sit down, I should pick up an important point made by the noble Lord, Lord Best, about the enforcement conduct authority. We are strongly supportive of the work that is being done by the Centre for Social Justice, in partnership with the enforcement and debt advice sectors, to set up an enforcement conduct authority to provide independent oversight of firms and to consider complaints. We believe that the proposed authority will make a real difference by raising standards in the industry to protect vulnerable debtors while improving the effectiveness of enforcement. We remain  committed to reviewing the new body within two years of its operation and then deciding whether it is necessary to put it on a statutory footing.
The noble Lord, Lord McNicol, referred to PPI. With respect, I am not persuaded that this is a like-for-like issue. The point with PPI is that people were paying sums which they should not have paid and which went into the pockets of the insurance companies. What has happened here is that VAT has been paid, but there is no suggestion that the enforcement officers have not been remitting the VAT which they collected to HMRC. We should look at each issue on its own merits.
To pick up the point made by the noble Baroness, Lady Boycott, I accept that the normal limitation point in claims for restitution, which this would be, is six years. However, to say that “the money actually belongs to them”—“them” being the debtors—is, with respect, to beg the legal question which is at the heart of the earlier dispute.
I apologise for rattling through that. This area is not without its complexity. We have sought to make the position absolutely clear going forward, and as regards past cases, I hope that I have set out the Government’s position with clarity, even if, as I suspect, it may not meet entirely with the noble Baroness’s approval. None the less, I hope that I have set out the Government’s position.

Baroness Meacher: My Lords, even before I thank the Minister, I owe the noble Lord, Lord Low, an apology. The Minister shot up rather quickly after the contribution of the noble Baroness, Lady Boycott, but I think the noble Lord, Lord Low, was planning to speak. I should have stood up and said something, and I apologise that I failed to do that.

Lord Low of Dalston: I am happy.

Baroness Meacher: I thank the noble Lord.
I thank the Minister for his response. I will make just a few tiny points. The Minister made quite a play on how not all debtors have overpaid the VAT sum or equivalent. In fact, 95% of debtors have been in this position and have been improperly overcharged, so we have to bear in mind that the vast majority of debtors are in this position.
The Minister indicated that of course creditors can be in great poverty. I point out to the Minister and your Lordships that we know that the vast majority of these cases involve utility companies and local authorities, not your little man with thruppence ha’penny in his pocket. So I do not think we can buy that one.
I am glad that the Minister accepted—I think—that the ministry should have acted earlier. Most importantly, I thank him for saying that the Government will be keeping an eye on the legislative process. That is our one bit of assurance. I, like others, thank Just very much indeed for pursuing this issue on behalf of these very vulnerable people. We have to rely on the courts to make a sensible decision; let us see how they go.
I thank the Minister but also very much thank noble Lords who have stayed around for an inordinately long time, waiting for this debate. I beg leave to withdraw my regret Motion.
Motion withdrawn.
Sitting suspended.

Health and Care Bill
 - Committee (2nd Day) (Continued)

Amendment 15

Baroness Hayman: Moved by Baroness Hayman
15: Clause 5, page 3, line 15, at end insert—“(d) how the decision is likely to contribute to—(i) compliance with the duty imposed by section 1 of the Climate Change Act 2008 (UK net zero emissions target),(ii) adaptation to climate change, and(iii) meeting other environmental goals (such as restoration or enhancement of the natural environment).”Member’s explanatory statementThe purpose of this amendment is to include, as part of NHS England’s duties, a requirement that when making a decision about the exercise of its functions, it must have regard to how any decision is likely to contribute to the UK’s climate change and environmental goals.

Baroness Hayman: My Lords, in moving Amendment 15 I will speak also to Amendments 43, 101 and 153 in my name. I also support Amendments 201 and 210 in the name of my noble friend Lord Stevens of Birmingham. I am grateful to him, the noble Lord, Lord Prior of Brampton, and the noble Baroness, Lady Young of Old Scone, for adding their names to my amendments. I should declare my interest as co-chair of Peers for the Planet, and my regret that I was not able to be present at Second Reading of the Bill.
I doubt that this debate will mirror the length and enthusiasm of so many participants around the Committee in the outstanding earlier debate. However, I should say that the issues that prompt these amendments are equally serious. The Government spent much of last year in preparation for the COP 26 climate meeting and all year, before and since, they stressed the gravity of the climate crisis that the country and the world face, the importance of making progress internationally and on our own domestic targets, which are statutory, and the importance of taking action across all departments and all sectors of the economy and the country’s activities.
The aim of these amendments is to embed consideration of the UK’s climate change and environmental goals throughout the Bill, in much the same way in which the noble Baroness, Lady Thornton, described how earlier amendments attempted to integrate throughout the Bill the issue of inequalities. I am disturbed, despite the Government’s commitments and despite the experience with other Bills—I look at the noble Earl, Lord Howe, who knows well that we have had similar debates on the Financial Services Bill. Those ended happily, and I hope that we can do the same on this Bill. But it is disturbing that we are still getting legislation through the House as if we were not  in the midst of a climate crisis and as if we did not have the most challenging targets on net zero, biodiversity and environmental change.
We turn to the NHS. I suggest to the Committee that the NHS has a vital role to play if the Government are to achieve their key strategic priority of net zero by 2050. The NHS is responsible for approximately 5% of the UK’s carbon emissions and around 40% of all public sector emissions. Recognising that, and with the outstanding leadership of my noble friend Lord Stevens of Birmingham, the NHS has committed to an ambitious net-zero plan. It was the first national health service to make net-zero commitments, and at COP 26 last year 14 other countries followed the NHS’s lead and set net-zero emissions targets for their own health services, illustrating how important domestic action can be on the global stage.
My amendments seek to integrate that overarching NHS plan into the new structures set up in this Bill and to join the dots between high-level policy and the new integrated care boards and care partnerships. They seek to embed climate and environmental considerations into the responsibilities and activities of NHS England, ICBs and ICPs, so that, throughout the NHS, climate action, environmental goals and climate adaptation are taken into account.
I should make clear that contributing to the achievement of net zero is important for the NHS not only in contributing to national targets for reducing the volume of emissions; it is also an important element in improving public and individual health. Rising global temperatures and air pollution, for example, directly contribute to rates of major diseases, including asthma, heart disease and cancer. Again, the link to the earlier debate about inequalities is very clear.
The Government themselves have recognised the link between reducing emissions and improving health, talking in their own net-zero strategy of the
“physical and mental health benefits”
of that strategy. The Climate Change Committee, in its progress report to Parliament last year, spoke of
“significant, tangible improvements to public health”
from reaching net zero. These views were echoed in the report from the Academy of Medical Sciences and the Royal Society, A Healthy Future: Tackling Climate Change Mitigation and Human Health Together, which was published last year. It is in the interests of the health of the country, as well as of the Government achieving their targets, to ensure that the NHS plays its part.
As I said earlier, the NHS itself has recognised the importance of this issue on both those counts and is committed to taking action, but we need to embed that commitment throughout the structures of the service. If my amendments are agreed to, this Bill can contribute by providing strategic direction and a clear policy framework at all levels of the NHS.
Amendment 15 adds to the list of the wider effects that NHS England has a duty to have regard to when making a decision about the exercise of its functions. Having heard the Minister respond to the earlier debate, I know that this will not necessarily be an attractive proposition to him, but I think it is important. If Amendment 15 is agreed, in addition to the matters  set out in Clause 5, NHS England would have a duty to have regard to how its decisions are likely to contribute to the UK’s climate change and environmental targets.
Noble Lords will recognise that the wording is broader than simply the achievement of our statutory net-zero commitments, but it may reassure noble Lords, and Ministers in particular, to know that it mirrors the terms of an amendment the Government introduced after a similar debate on the Skills and Post-16 Education Bill. Importantly, the wording includes the “adaptation to climate change” necessary to build resilience within the healthcare sector and protect the health of our current and future populations. This reflects the recognition in the NHS’s own net-zero strategy and adaptation report that climate breakdown may affect the healthcare system with increasingly adverse environmental conditions. It is sobering to note that, over the last 15 years, at least 15 hospitals have experienced major flooding incidents, causing disruption to patient services or hospital support services. Attention to vulnerability in this area needs to be an important focus for NHS England.
Amendment 101 would impose a similar new duty on integrated care boards to contribute to the same three objectives set out in Amendment 15, ensuring that trickle-down of policy objectives through the system.
Amendment 43 also deals with integrated care boards, mandating that their constitutions must provide for a member to be designated—not appointed, I should make clear, but for an appointed member to be designated—as having responsibility for climate change and the environment. This would reflect the NHS’s net-zero plan, which highlights the importance of
“ensuring that every NHS organisation has a board-level net-zero lead”.
This amendment implements that part of the plan in relation to the new framework of ICBs, created in the Bill, and having a board-level lead is an approach which has proved successful in other sectors.
Amendment 153, the fourth in my name, deals with the preparation of strategies by integrated care partnerships. It seeks to add to the issues already set out in the Bill, to which the ICPs must have regard when setting strategy, the UK’s net-zero target
“adaptation to climate change, and … environmental goals”.
I look forward to the comments of my noble friend Lord Stevens of Birmingham on his Amendments 201 and 210, dealing with procurement and payment issues, to which I have added my name and which I support. Obviously, I look forward to contributions from the Committee and a response from the Minister, which I very much hope will be positive. I beg to move.

Lord Stevens of Birmingham: My Lords, it is a great privilege to follow the noble Baroness, Lady Hayman, and support all the amendments in this group in her name. I speak particularly to Amendments 201 and 210 which, as she said, refer specifically to using the purchasing power of the NHS to drive this agenda. Given how brilliantly she has set out the case, I shall be extremely concise.
There are two evidence-based reasons why these amendments are important. The first, as the noble Baroness said, is because the health consequences of the environmental crisis are increasingly clear. The Royal Society and the Academy of Medical Sciences laid all of those out. Whether on heat-related deaths, the disruption to care through climate emergencies, the increased risk of vector-borne infectious diseases, or the fact that up to a third of preventable asthma cases may be linked to the consequences of air pollution, the health case for action is clear. The second evidence-based reason, again as we have just heard, is that unfortunately healthcare itself is not blameless. It is part of the problem as well as part of a solution. By one estimate, if all the health systems in the world were their own country, they would be the fifth-largest greenhouse gas emitter on the planet. Therefore, the NHS must get its act together, given that it contributes 4% to 5% of our country’s emissions.
Those are the two evidence-based reasons. The NHS has stepped up in the way that the noble Baroness has set out. An expert panel led by the brilliant Dr Nick Watts made it the first health service in the world to charter a practical blueprint to net zero, but to do that, we must recognise that only about 28% of the carbon footprint of the NHS arises directly from care being provided. Another 10 percentage points are associated with travel on the part of patients, staff and visitors, but 62% of the carbon footprint arises from the supply chain—the medicines, the devices, the anaesthetic gases, the asthma inhalers, that the NHS uses, which it procures from 80,000-plus suppliers.
I am grateful to the noble Lord, Lord Prior of Brampton, and the noble Baronesses, Lady Young of Old Scone and Lady Hayman, for their support of my Amendments 201 and 210. Their purpose is simply to harness the £150 billion of purchasing power that will flow through either the new NHS payment system or the procurement rules to achieve the two evidence-based rationales that we have been discussing.

Baroness Northover: My Lords, this is my first foray into this Bill. I have a sense of déjà vu, having deputised for the noble Earl, Lord Howe, on the 2012 Bill. Despite our absolute confidence at the time, it seems that some things need to be tweaked and rectified, though I now find myself on this side and the noble Earl on the other.
From these Benches, I support these amendments. The noble Baroness, Lady Hayman, put it very effectively. Climate change needs to run through to the very foundations of the Bill, as does addressing the health inequalities which were the subject of the previous debate. We have had such a long-standing debate about them over the years.
As the noble Baroness has said, at the moment, the UK is taking the lead internationally on combatting climate change through COP 26 and in the year after. We have been urging the world to take urgent, deep-rooted action if the enormously damaging effects of climate change are to be tackled and reversed. We know that the poorest will be hardest hit and can already see that effect, but no part of the globe will be spared. We can already see this as well.
As the noble Lord, Lord Stevens, said, we also know the effects on human health worldwide. We can see them already in developed countries: we saw the effect of that heat dome in Canada and the deaths that resulted from it. We know that climate change might have played a part in seeding the pandemic from which we have suffered during the last two years. We know all that. We also know that we cannot lead internationally without addressing climate change nationally. I pay tribute to the staff supporting Peers for the Planet, a group of which I am a member, for making sure that we address climate change at every stage, in every Bill.
We are rightly proud of the NHS. It is the major employer in the United Kingdom. The health and social care of our ageing population will play an ever more important role in our lives. It is therefore right that, in the Bill, as in every other area of life, tackling climate change must run as a thread through all we do. The Climate Change Committee makes this clear. It is not something for only Defra or the COP team. It requires fundamental change in everything we do and the scrutiny of every area of life.
The NHS has already made strides forward. Here, I pay tribute to the noble Lord, Lord Stevens, in making sure that that was the case. At COP 26, the NHS made a commitment to net zero. As we have heard, 14 other countries followed the NHS’s lead. More than 50 countries, representing more than a third of global healthcare emissions, have committed to developing sustainable, low-carbon health systems. This is incredibly encouraging. It is also encouraging that, at COP 26, a new international platform was set up—to be hosted in partnership with NHS England and the WHO—to bring together those in the healthcare systems, so that people can learn from each other.
Why does this matter? As the noble Baroness, Lady Hayman, has said, the healthcare sector is responsible for almost 5% of global emissions. Of course, public health is assisted by tackling climate change. Although we pay tribute to what the NHS has managed to do so far—and it is ahead of its requirements under the Climate Change Act—we need to make sure that this is built in and sustained for the future. This is what these amendments are about. Progress is being made, but we need to ensure that it is locked in and does not necessarily depend simply on who is leading these organisations at any particular time.
The noble Baroness, Lady Hayman, has explained how her first amendment affects the overarching structure within NHS England. The other amendments put in place the necessary pragmatic steps to make sure that this is addressed. Thus, we have identified individuals for these particular responsibilities. This is obviously of key importance.
It is fundamental that, in addressing climate change, we do not just see this as hosting a major meeting or siloed in one department—whether Defra or BEIS. I am a member of the Select Committee on the Environment and Climate Change. When our committee asked the different departments to report on what they were doing in advance of COP what came back to us, in many regards, was a kind of surprise that they were relevant to it. They felt that it was something for Defra, for BEIS in particular, or for the COP unit.  They did not see it as their responsibility. Some of the responses were superficial in the extreme. That is why it is important to make sure that we mainstream this issue, and this is another opportunity to do so. I strongly support the amendments that the noble Baroness, Lady Hayman, and others have tabled.

Baroness Bennett of Manor Castle: My Lords, it may not surprise your Lordships’ House that as a Green Peer, I rise to offer my full support to all these amendments. I also declare my involvement with Peers for the Planet.
In introducing this group so comprehensively and, I would say, brilliantly, the noble Baroness, Lady Hayman, said it was just important as the group that we were discussing previously, which addressed inequalities in issues such as smoking and alcohol and their impacts on health. I would actually go further and say that the two groups are intimately related, in that when someone arrives at the NHS needing treatment for an illness or a disease, at a point where their environment and society, often, has failed and has created or amplified that disease, the NHS then has to deal with the problems created by society and that environment. We need a systems-thinking approach to health—not just “Here’s a disease” or “Here’s a limb or an organ with a problem” —that considers the whole person. I say in passing that I regret that I was not able to take part in that earlier group due to my being unable to be here at the start.
I am not going to run through all the amendments, which have been very well covered, but they go all the way from the duty of the NHS to have regard to climate and the environment, right down to the detail of procurement. I particularly commend the noble Lord, Lord Stevens. We would like to see the Government take control of procurement more broadly to improve our society. The Preston model comes to mind here.
I want to address the climate side of this issue, and then I am mostly going to talk about the environmental side, which has not been discussed much yet; I want to add something different rather than repeat. However, I have to highlight the fact that we are talking about 5% of UK climate emissions and 40% of public service emissions.
We really have to think about the interrelationship of environment and health. We know that heatwaves have huge impacts, particularly on the health of older people. They can be a significant cause of death among older people, and as long as the NHS contributes to climate change, there is a disastrous cycle there. Also, some 10% of London hospitals are at risk of river flooding. I have not been able to find figures for the country as a whole, but I am sure that will be true for many other hospitals too.
While preparing for today’s debate, I looked at the Medicines and Medical Devices Act, which we debated last year. It is a little unfortunate that, as I look around the Chamber today, practically no one is present who attended those debates. That Act was a huge missed opportunity. It requires that when the appropriate authorities are approving veterinary medicines, they must have regard to their environmental impacts. I moved an amendment—but lost the vote—that would have applied the same judgment to human medicines.  This point applies particularly to antibiotic resistance. I am not going to repeat everything I said in Committee on 26 October, but it is all there. The management of antibiotic resistance is a huge issue that the NHS needs to do a great deal more on, as do all global health systems.
I want to focus on some other aspects of the environmental impacts of the NHS today, particularly in light of the report by the Environmental Audit Committee in the other place on the state of our rivers. The Bloomberg Green newsletter going around the world today has the following headline:
“English Rivers Join Europe’s Most Noxious with Chemical Cocktail”.
That report notes, as have many others, that:
“No river … received a clean bill of health for chemical contamination.”
Discussion of this issue often focuses on the behaviour of water companies, and untreated sewage. But even if we tackle that problem and get the sewage treated, sewage treatment will be unable to deal with some of the medical products that impact water quality. There are also impacts on air pollution and soil contamination, as I will set out.
We have to look at this in the context of Covid. The UK healthcare sector alone has seen the demand for face masks rise by 4,700% to 85 million to 90 million per month. The use of single-use aprons and gloves has grown by 550% and 200% respectively. The vast majority of these are made from plastics coming from fossil fuels. This has other huge impacts. If they are incinerated after their single use, there are more carbon emissions and toxic gases such as dioxins and furans, and toxic ashes. If they go into landfill they will persist for hundreds of years, potentially leaching toxic chemicals into the soil.
Commendably, the NHS has a pilot project to introduce reusable IIR-certified face masks, showing that it is possible to do things differently. But this is a pilot project and not something happening at scale. Surgical masks were reusable until the 1960s, and there were no issues of infection prevention and control. At the time they were shown to be of equal or even better quality than the single-use alternatives. However, large scale production has now stopped, so it is hard to make a comparison in the current situation. Many hospitals have closed their on-site cleaning and sterilisation facilities, which has pushed them further towards single-use products. This is not just an environmental issue. In the United States, UCLA Health has saved an average of $450,000 a year just by switching to reusable gowns. As a rule of thumb, reusable gowns and other such materials have a 200% to 300% lower carbon footprint and reduce energy, water and other resource consumption.
It is not just a question of the plastics in the protective materials, but what else is in them. Consider PFAS, a large family of organic synthetic chemicals which are linked by the carbon fluoride bond. These are often known—you will see the headlines—as “forever” chemicals because they never break down. They have been found in penguin eggs in Antarctica and polar bears in the Arctic. Recently, a study by Stockholm University published in the Environmental Science &  Technology journal showed that although it had been thought that we could dump them in the oceans and that would get rid of them, waves bring them back into the air and on to land; they are circulating everywhere. They are typically impregnated into a liquid-repellent finish on single-use surgical gowns and drapes, and they are also found in ambulance jackets. This demonstrates the seriousness—we still do not know how serious—of the problem. There are definitely huge impacts.
While I am on gowns, I point out that there has been a huge trend towards treating surfaces with biocides. But we then come back to the problem of antibiotic resistance that I referred to earlier. Experts say—I note Health Care Without Harm’s work on this issue—that there is no evidence that they have any positive impacts on reducing infection.
So, what does this mean in terms of scale? On average, about 20% of the active pharmaceutical ingredients in wastewater come from healthcare facilities. That is a far from negligible amount. Of course, a lot of them also come from household use of medicines. In November, Health Care Without Harm published a really useful report on this. It contains five case studies, demonstrating how some European hospitals are dealing with these issues. Examples include the use in Germany of
“urine bags to keep iodinated contrast media out of the water cycle”,
and “thermal plasma” research in the Netherlands. There are things that can be done, and much more that needs to be done.
I am aware that I have been quite technical, but these are really important issues that we want to get on the record. I gave the Minister prior notice of a question that I planned to ask, which refers again to a Health Care Without Harm Europe report. It produced a list of chemicals of concern that it says we should seek to phase out from the entire healthcare system. Quite a number of regional health groups, hospitals and medical groups across Europe have signed up to seek to ensure that the chemicals on this list, which has a very detailed and serious eight-point set of criteria, are phased out. Are the Government ensuring that NHS England takes account of and acts on this list, and takes the kind of steps that we are seeing taken in Europe to eliminate these chemicals of concern from our healthcare system?

Baroness Walmsley: I support these amendments and in particular the words of my noble friend Lady Northover. I too am a member of Peers for the Planet and, as a biologist, I have been devoted to trying to address climate change ever since I knew anything at all about it. I particularly support the noble Baroness, Lady Hayman, in her determination to mainstream the issue. It is not the responsibility of just Defra but every department of government and every single individual in this country.
From my work on the Science and Technology Committee, I was aware of the health service’s 5% contribution to our emissions, but also of what the NHS has already done and pledged to do under the leadership of the noble Lord, Lord Stevens. I confess I was a little surprised when I saw these amendments; I thought,  given all that, “Why does the noble Lord think more needs to be done?” The noble Lord, Lord Stevens, knows more than I or any of us do about the health service, so if he thinks more needs to be done, I am with him. We absolutely should support these amendments.
I would like to ask the Minister one particular question. The NHS has a very large portfolio of property and the Prime Minister has promised 40 new hospitals in a certain period of time. Leaving aside the fact that some of the buildings promised are not hospitals and are not new, if we are building new buildings, I would like to be assured that all of them will be zero-carbon. That can be done and there is no excuse not to do it.

Baroness Wheeler: My Lords, I congratulate the four noble Lords who have produced this excellent suite of amendments across the Bill to ensure that ICBs procuring or commissioning goods and services on behalf of the NHS are firmly focused on their responsibility for NHS England’s commitment to reaching net zero by 2040. It has been an excellent and informed debate, and one with much enthusiasm to reassure the noble Baroness, Lady Hayman.
We fully support the amendments and have little to add from these Benches following the expert contributions of those proposing the amendments and the other noble Lords who have spoken. I am sorry my noble friend Lady Young, who put her name to the amendments, cannot be here. She was a key member of our team during the recent passage of the Environment Bill, and her expertise and wisdom always guides and reflects our approach. The House is clearly interested in this vital matter, as we saw this week in an important Oral Question on the Prime Minister’s promise for a new, overarching net-zero test for new policies. Assuming the Government fully support the key commitment from NHS England, I hope that, in his response, the Minister will accept the need for the amendments and will not argue that the proposed new clause is unnecessary as NHS England already has a commitment that will percolate down to ICBs.
As we have heard, the power of public sector procurement is a massive issue and there is no bigger part of the public sector than the NHS. The NHS has such an important impact on other environment issues, such as waste, pollution and resource consumption, especially for plastics, paper and water. We should ensure we are on the front foot in using that impact to deliver the net-zero commitment.
The NHS has made a start, but there is much more to do. These amendments would reinforce the importance of action in these areas for the new bodies and processes that the Bill creates. The NHS is a big player and, as noble Lords have stressed, it can play a big role in tackling all of these climate change and environmental challenges. Procurement is a strong lever that the NHS can utilise in key markets, particularly in those areas where it is the sole purchaser. The noble Lord, Lord Stevens, was very eloquent on this issue and I look forward to the Minister’s response in the light of his contribution.
Like other speakers today, my noble friend Lady Young wanted to stress that action so far is only the beginning. In the light of the importance of climate change and other environmental challenges, we strongly  support such a duty being in place for all the public and private bodies with significant impacts when future legislation comes through Parliament. We did that when inserting a sustainable development duty into the remit of every possible public body from the late 1990s onwards, but this time it has to be not only enacted but managed, delivered, tracked and reported.
As the Minister, the noble Lord, Lord Callanan, told the House this week, every sector of government needs to do its bit, and we need to hold them to that. These amendments are vital, since every public body will have to take further action this decade if we are to restrain temperature rises to two degrees—far less, 1.5 degrees.
Finally, I too thank Peers for the Planet both for its work and, especially for me, its excellent briefing. As noble Lords have stressed, the NHS has committed to net zero and aims to be the world’s first net-zero national health service. It is responsible for around 5% of the UK’s carbon emissions. That is why the NHS’s role and contribution to net-zero targets should be fully integrated into the Bill. I look forward to the Minister’s response and his detailing of how the NHS is to achieve its ambitions. I hope that he will acknowledge that its commitment must be in the Bill. These amendments present a vital opportunity to enshrine in law a commitment that I think most, if not all, would want to see delivered.

Lord Kamall: I thank the noble Lord, Lord Stevens, for the amendments and the noble Baroness, Lady Hayman, for her opening remarks. I also thank the noble Baroness for her suggestion yesterday that it might make my life a lot easier if I just accepted amendments. I understand that advice, having just gone through a two-hour debate on the previous group.
A number of noble Lords referred to how these amendments relate to our previous debate on inequalities. I point out that that is sometimes not quite in the way that we would expect. We might think there is a direct connection, but sometimes the green agenda can be seen to be for those who can afford it—as I explained before, for the white, middle-class, patronising people who tell immigrant working-class communities what to do and push up their costs. Anti-car policies push up costs for those in rural areas, and there are higher fuel costs as we replace gas boilers with potentially more expensive heat pumps. We have to be aware of those issues. In the long term, I am optimistic. I look forward to the day when we have solar power and wind power, with storage capacity, which will reduce costs.

Baroness Northover: Will the Minister look at this globally and recognise that the poorest are affected the worst? When he talks about those in poverty, he should think globally.

Lord Kamall: I accept that point, but I also accept that, sometimes, one can be patronised, and I do not accept being patronised as I was in the earlier debate. One day, there will be cheaper fuel, and we can look forward to it, but we have to make sure that the transition along the way is not seen to push up costs for working people, because we all feel passionately about this green agenda.

Baroness Bennett of Manor Castle: The Minister was talking about the impact of policies on the poor. Does he agree that many of the products—the fabrics, the chemicals—are manufactured in the poorest areas of the world, producing pollution that has disastrous impacts on some of the poorest people?

Lord Kamall: I was going to come to the noble Baroness’s points, and I am grateful to her for raising these issues directly with me previously.
Turning to the amendments, I thank the noble Baronesses, Lady Hayman and Lady Young of Old Scone, and the noble Lords, Lord Stevens and Lord Prior, for bringing this debate before the Committee. There is no doubt that the NHS has a significant carbon footprint. There is no doubt that a poor environment has direct and immediate consequence for our patients, the public and the NHS. There is no doubt that it has an impact on the health of the nation. As the noble Baroness, Lady Hayman, pointed out, the NHS accounts for around 4% to 5% of UK emissions. If we go further, as the noble Baroness, Lady Bennett, said, that is 40% of public service emissions. Noble Lords are right to highlight the critical role that the NHS has to play in achieving net zero.
To support that work, NHS England—thanks in part to work already started by the noble Lord, Lord Stevens, who I know has had conversations with my right honourable friend the Secretary of State for Health and Social Care—is leading the way through a dedicated programme of work, as many noble Lords acknowledged. This includes ambitious targets for achieving net zero for the NHS carbon footprint by 2045 and for its direct emissions by 2040. This is ahead of the target set by Section 1 of the Climate Change Act 2008; we welcome that ambition and will continue to support the NHS in that.
In response to the question from the noble Baroness, Lady Northover, on what the NHS and Department of Health and Social Care are doing, as part of this programme of work, under the 2021-22 NHS standard contract, every trust is expected to have a green plan. As NHS England has already made clear in its guidance on green plans, published in June 2021:
“Every trust and every ICS is expected to have a Green Plan approved by that organisation’s board or governing body. For trusts, these should be finalised and submitted to ICSs by 14 January 2022. Each ICS is then asked to develop a consolidated system-wide Green Plan by 31 March 2022, to be peer reviewed regionally and subsequently published.”
I hope the noble Baroness will accept that as some real action.
We would then expect the current ICSs regularly to review and consider progress against their green plan, and in the future for the boards of both the ICB and the ICP to regularly consider where they can go further, faster. If they can meet targets faster, so much the better. If ICBs and ICPs can learn from each other and from best practice, so much the better. As we alluded to in the previous debate, sometimes the solutions are to be found at local level and not necessarily from the top down. If we can learn from the best social enterprises and others, I think we can go a long way.
On the specific question of procurement, the NHS is already publicly committed to purchasing only from suppliers who are aligned with its net-zero ambitions by 2030. Last year, NHS England set its road map, giving further details on the expectations of suppliers to 2030. Once again, I hope noble Lords will accept that as real progress.

Lord Mawson: I thank the Minister. Can I just give an illustration about the local on this issue? I am certainly not an expert on climate change, but I am a practical person who worries a lot about granularity and the gap between a lot of talk I have heard over many years on all sides of this Chamber—with very large amounts of money cited, et cetera—and the realities in this building.
I am trying to buy an electric car at the moment, as a responsible citizen. When I went to have a look at the multi-storey car park below this building—the local—and wondered where I am going to plug it in when it arrives here, I ended up talking to one of the facilities managers, who was a very nice man. I asked him how many plug-in points there were underneath this building—again, the local. He said, “I don’t know, Lord Mawson, but I will look into this”.
He was diligent and came back to me. We started to have a conversation about it, and he began to suggest that I need to carry a cable in my car with a three-pin plug. I pointed out that my office is across St Margaret Street, in Old Palace Yard, on the third floor, so maybe I should run it across there with a carpet over it and up to the third floor to plug it in there. We had this amusing conversation. I said, “Well, go on then, tell me: how many are there in this building, where all this chatter and talk is taking place?” His answer was that there are two. I suggest that the gap between reality and rhetoric is very large indeed. If we are really going to deal with these issues—as we must—we must now become intensely interested in the NHS and in all the systems of government about practicality and the procurement machinery, which I suggest is not working.
I talked to one of the facilities people yesterday about my office, which has a light switch with a notice over the top of it telling you how to use it. It is completely ludicrous. She told me that that system is going to be different to all the systems here in the Palace of Westminster; none of it is joined up.
I think the Minister is right. The clue is in the local, but all our systems and our civil servants must now become interested in practicality and the local if we are really going to get serious about these matters. It is absolutely crucial to get procurement right, because without that, we will never deliver this.

Lord Kamall: I thank the noble Lord, Lord Mawson, for that intervention, and I completely agree. There are some incredibly inspirational projects going on in our local communities, tackling and addressing the green agenda, and sometimes, top-down, we may feel good about it in this place, but it really affects working people and those who face higher costs and we have to be very careful.
On the specific question of procurement, the NHS is already publicly committed to purchasing only from suppliers which are aligned with its net-zero ambitions  by 2030, and last year, NHS England set out its roadmap giving further details to suppliers to 2030. This is supported by a broad range of further action on NHS net zero and we hope that by pushing this through at NHS England level, but also with ICSs, we can see some of that local innovation as local trusts and local care systems and even health and well-being boards respond to those local challenges—others could learn nationally. To respond to the question of the noble Baroness, Lady Walmsley, NHS England will publish the world’s first net-zero healthcare building standard; this will apply to all projects being taken forward through the Government’s new hospital programme, which will see 48 new hospital facilities built across England by 2030.
There is political consensus on green issues. and we should pay tribute to the noble Baroness, Lady Bennett, and the Green Party for making sure, over the years, that the green agenda has been put at the centre of British politics. We find green policies in all the election manifestos of the mainstream parties: that is in no small part due to the noble Baroness’s party and to the noble Baroness herself. So, even while we may disagree on how to achieve some of these things, there is no doubt that we are not going to reverse on our commitment. Whatever Governments are elected in future, all are committed to a carbon net-zero strategy and a cleaner environment. So, I must gently disagree with her that these amendments are necessary.
I would like to have further conversations with the noble Lord, Lord Stevens, given his experience, on why he feels that, despite all the great work that the NHS has been doing, these amendments are still necessary. I would like to have further conversations with him and others, but at this stage, I ask the noble Baroness to withdraw the amendment. Across the political spectrum, we must make sure that we are pushing the NHS to deliver, not only at the national level but at the ICS level and even lower, at the place level that the noble Lord, Lord Mawson, speaks so eloquently about.

Baroness Bennett of Manor Castle: Before the noble Lord sits down, will he respond to the question, of which I gave him prior notice, about the document?

Lord Kamall: I apologise to the noble Baroness—I am so sorry, but I am trying to juggle 300 devices. That is a slight exaggeration, if I am honest. We recognise the importance of ensuring that all chemicals in the NHS supply chain are appropriate and properly managed as part of the net-zero strategy. I think the noble Lord, Lord Stevens, even touched upon some of the chemicals that were used and some of the issues he looked at during his time at the NHS when it comes to chemicals. The NHS must also comply fully with the Control of Substances Hazardous to Health Regulations, the CoSHH regulations.
More broadly, although Defra is the lead department for harmful chemicals, the UK Health Security Agency feeds in its expertise in relation to restricting and banning chemicals, and we are grateful to it for that work. The UKHSA is also looking at each of those chemicals, which we hope in future can be replaced by less harmful materials and chemicals. I undertake to write to the noble Baroness in more detail than the short answer I have given her at this stage.

Baroness Hayman: My Lords, I am extremely grateful to all Members who contributed to this debate, which got slightly more feisty than I expected it to do in some areas. I am sure that the Committee will be grateful if I do not respond on the issue of electric charging points in your Lordships’ House, which has concerned me for four years, but there are one or two important things to be said here. There are two dangers. One danger—I fear the Minister nearly got there—is to suggest that those who are concerned about climate are not concerned about fairness or inequality and do not realise the dangers, on everything from heating to electric vehicles or whatever. However, there is not that layer of people who are concerned only with the climate in theory. Most of us who are active in this area are extremely concerned about a fair transition and the implications of individual policies.
The other false dichotomy is that either you work on the absolutely granular local stuff or you make highfalutin legislation that is not relevant to anyone. We need both. We need to go throughout the system. We are legislators. Legislation matters and words matter. Sometimes legislation matters because Governments and policies change but legislation is there in statute—the words are on the page.
Of course I will seek to withdraw my amendment and of course I will have conversations with the Minister, but it is essential that we tackle this, the most serious of issues facing the world. Covid is the crisis of our time but the climate is the crisis of our age and we absolutely need to address it at all the levels that we can—and there are many. As I say, we are legislators and we can start some of that trickle-down. We have a responsibility to monitor and ensure that we end up with exactly the level of granularity that we need—and that we learn from the local. I am happy to delay conversations with the Minister for a later date. I beg leave to withdraw my amendment.
Amendment 15 withdrawn.
Amendment 16 not moved.
Clause 5 agreed.

Amendment 17

Baroness Morgan of Cotes: Moved by Baroness Morgan of Cotes
17: After Clause 5, insert the following new Clause—“Duty to consider residents of other parts of UKFor section 13O of the National Health Service Act 2006 substitute—“13O Duty to consider residents of other parts of UK(1) In making a decision about the exercise of its functions, NHS England must have regard to any likely impact of the decision on—(a) the provision of health services to people who reside in Wales, Scotland or Northern Ireland, or(b) services provided in England for the purposes of—(i) the health service in Wales,(ii) the system of health care mentioned in section 2(1)(a) of the Health and Social Care (Reform) Act (Northern Ireland) 2009 (c. 1 (N.I.)), or(iii) the health service established under section 1 of the National Health Service (Scotland) Act 1978.  (2) The Secretary of State must publish guidance for NHS England on the discharge of the duty under subsection (1).(3) NHS England must have regard to guidance published under subsection (2).””Member’s explanatory statementThis new Clause places a duty on NHS England to consider the likely impact of their decisions on the residents of Wales, Scotland and Northern Ireland, and to consider the impact of services provided in England on patient care in Wales, Scotland and Northern Ireland.

Baroness Morgan of Cotes: My Lords, in moving my amendment I will speak also to Amendments 205 and 301. I thank my noble friends Lord Moylan and Lady Fraser of Craigmaddie for their support for these amendments.
It is a pleasure to follow two excellent debates. I suspect—although, as the noble Baroness, Lady Hayman, said, we are never quite sure how feisty the debates on these groups will get—that we may spend an even shorter time on this group to enable the Committee to make progress. These amendments are relatively simple, designed to improve transparency, quality and access to healthcare for residents in all parts of the United Kingdom. I thank Ministers for their engagement so far on the amendments. In particular, Amendments 205 and 301 were tabled in the House of Commons by Robin Millar MP and others.
The NHS is a UK institution. It could not have been developed without the combined economic strength of our United Kingdom and has developed from unifying United Kingdom values—you might even say that the NHS embodies them. It includes a promise that, wherever in the United Kingdom you are from and whatever your situation, you are entitled to the same protection and treatment. That is why the first two amendments, Amendments 17 and 205, are about access by patients to a consistent national standard of healthcare.
The unfortunate reality, of course, is that many UK residents do not have equal access to healthcare. Referral-to-treatment waiting times for England, Scotland and Wales are, respectively, 11 days, 32 or 42 days—depending on whether you are talking about in-patients or out-patients in Scotland—and 21.5 days. These headline figures are concerning enough. However, they obscure even more stark differences when treatments are considered separately.
For example, in Wales, waiting times in Swansea for routine shoulder, hip and knee operations before the pandemic averaged, respectively, 128 weeks, 120 weeks and 103 weeks. By comparison, 95% of routine hip replacements and 94% of knee operations in England at that time—of course, we all know how very difficult and challenging the last two years have been for waiting lists in our NHS—were taking place within 18 weeks, a seventh of the time.
Although we, in both this House and the other, often talk about people living in one area or another, or one country or another, patients and their families do not think like that; they do not think about barriers and borders. They simply want the best treatment, and if necessary they are prepared to travel to get it in an  appropriate time, particularly where, as many people will know, without that necessary treatment their quality of life is literally endangered.
Amendment 301 is about improving public services, because the key step towards improvement of public services is securing transparency, scrutiny and accountability. Data that is not collected or not comparable limits public access to information about the quality of the public services that those who pay for them are entitled to expect. As a result, if that information is not easily available, elected leaders avoid pressure to improve those public services.
For example, cancer referrals in England and Scotland both have “test within six weeks” targets. However, comparisons are frustrated by different numbers of tests—there are eight tests in Scotland and 15 in England—and different measures for when the period ends. It is until the last test is complete in England, but until the report is written up in Scotland.
England has condition-specific targets for children’s mental health—for example, children with eating disorders must be seen within a week—whereas Scotland has a generalised target of seeing a specialist within 18 weeks, for all conditions.
I have already mentioned orthopaedic surgery, but Scotland and England have that 18-week target for hospital admission for knee and hip replacements. However, those unavailable for treatment due to ill health, work or family commitments are discounted from statistics by Scottish but not English trusts. Patients waiting in Scotland who are suffering chronic pain are discounted from orthopaedic waiting lists unless they choose to opt in for treatment.
This pattern has continued during the pandemic. In one example, an extra 300 care home deaths were identified in Scotland when a media campaign forced the revelation that the original figures had excluded residents who died in ambulances and intensive care units.
Comparable health data helps everyone. Access to data on waiting lists and outcomes helps both healthcare professionals and patients make informed decisions about referrals, treatments and where to live. As we have seen in the last two years, when the quality of data in relation to Covid-19 cases and treatments has improved beyond all recognition, a larger pool of healthcare data drives better public health policy and intelligence on population health.
I thank noble Lords who have expressed an interest in these amendments and Ministers who have engaged so far. I look forward to hearing from the Minister on these important amendments, which are really all about recognising, as I said at the start of my remarks, that the NHS is a UK institution embodying United Kingdom values.

Baroness Fraser of Craigmaddie: My Lords, I am very keen to speak to these amendments. This is the first time I have been able to contribute to this Bill, and I apologise for not being here for Second Reading. I was actually talking to Members of the Scottish Parliament about NICE and SIGN guidelines on the day of Second Reading, so I am delighted to have  an opportunity to contribute now. I will speak to Amendments 17, 205 and 301. I thank my noble friend Lady Morgan of Cotes for tabling them; I would have added my name to all three if I had got in quick enough.
We all appreciate that health and care are devolved matters. As my noble friend outlined, the Scottish Administration have taken a very different path on health and care over recent years, which perhaps could be characterised as worrying less about long-term funding and pursuing a more centralised approach. The Bill is therefore predominantly and rightly focused on matters relating to England, but a number of clauses addressed by these amendments relate to devolved areas. I note that the Scottish Government and the Cabinet Secretary for Health in Scotland have yet to grant the Bill legislative consent, believing that some clauses do not reflect the devolution agreement. I beg to put that these amendments are slightly different, in that they do not cover a specific area of delivery within devolved nations.
Amendment 17 simply covers how NHS England should consider the impact of any decisions it might make on patient outcomes in the devolved Administrations. Amendment 205 protects the right of access to treatment and services for all citizens throughout the UK. Amendment 301 seems to be simple common sense, in that it ensures the interoperability of data and collection of comparable healthcare statistics across the UK.
I support these amendments on a number of counts. First, the pandemic has highlighted the huge importance of good data, and close collaboration and working, throughout all health and care services in all parts of the UK—whether that is knowledge gathering, information sharing, vaccine development and rollout, or anything else. The pandemic has demonstrated yet again that we are “better together”. In the realm of healthcare, I support any measure that ensures that we do not work in silos and that barriers are not created in the provision of healthcare that prevent seamless co-operation throughout the UK. This will become ever more important as roles change, technology advances and services develop.
We particularly need to ensure a UK approach to data gathering and healthcare statistics, as set out in Amendment 305. The disparities do not just present a barrier to consumers of healthcare—the public: voters, indeed—and their understanding and ability to evaluate standards of care in their area, as my noble friend Lady Morgan just illustrated. The lack of interoperability of data has real and detrimental consequences for health research, patient care, and ensuring and promoting continuous improvement in healthcare. This is before we even consider inconvenience and inefficiency.
My eldest daughter stands in danger of being caught out by the current unsatisfactory situation. As a student at the University of St Andrews, she had her first two Covid vaccinations in Scotland, recorded on the NHS Scotland app under her CHI number, which is the number that NHS Scotland uses to identify patients. By the time it came to her booster and third injection, she was working as a graduate trainee in London. She duly went along in December and queued at a drop-in centre for her booster. However, the two systems do not match, so nowhere can she now show her proof of having three doses of the vaccine—which might lead  to some problems if she wants to go to the rugby, a nightclub or somewhere else where she has to show it; or if she wants to travel. The same situation has arisen for many students or others who regularly cross the borders of the United Kingdom for work, study or family reasons. For these reasons, I commend the Minister to look at initiatives such as patient-held records. After all, we should always remember that, importantly, this is the patient’s own data.
Another challenge we faced at the beginning of the pandemic was when consultants across the four nations sought to identify who should be in the shielding categories. Ensuring that the right people with the right conditions were identified and then notified was made far more challenging by the disparity of health data for different populations. It is bad enough that primary care, secondary care and social care data do not speak to each other, but healthcare is far too important to be allowed to become a political football within the UK.
The Prime Minister has put ensuring the viability and security of the union as one of his top priorities. We have heard the excellent recommendations of my noble friend Lord Dunlop, and many times in this Chamber we have been assured that the recommendations will be enacted by Ministers across government departments, so that decisions taken in Westminster and England that affect the devolved nations will be considered proactively, positively and constructively, and we can build mutual respect. This Bill and this moment are an ideal opportunity to put some of these principles into practice. What could be more positive and constructive than legislating for NHS England to ensure that this body considers the impact of its decisions on patient care in Scotland, Wales and Northern Ireland?
Like Amendment 301, where better data will lead to greater transparency, the new clause proposed by Amendment 17, which aims to ensure that the Secretary of State publishes guidance on these matters, also goes some way to ensuring transparency, which is so important in the building of mutual respect. These amendments would ensure that those with different approaches and political views across the UK cannot simply manipulate the delivery of healthcare and sacrifice patient outcomes on the altar of division.
Turning to Amendment 205, at the moment, if a treatment is available to patients in one of our bigger teaching hospitals—say, in London, Glasgow or Edinburgh—should that treatment not be available to anyone in the UK? I refer to my interests in the register, particularly as the chief executive of Cerebral Palsy Scotland. I recall that, when the procedure for children with cerebral palsy, known as selective dorsal rhizotomy, was first performed in the UK, it was available at first only in Bristol. However, NHS boards in Scotland were able to refer suitable patients on an ad hoc basis, with funding following the patient. This saved families having to raise around £80,000 to travel to the United States for the procedure—but it did not just help the families. The practice was able to ensure that good practice and learning were shared. Now, the procedure, pioneered in Bristol, is available in a number of areas across the UK.
Specialist, life-saving cancer services are another example. I think of a recent case where a patient from Glasgow—a good friend of mine—was able to benefit from treatment in Liverpool, which was his only option for treatment in the UK. However, it is not just for rare procedures or difficult cases that this is applicable. I have often seen families of children with cerebral palsy from Belfast, Carlisle or Northumberland who wish to travel to Glasgow or Edinburgh for relatively routine but condition-specific input instead of having to travel to London. At the moment, as I said, these arrangements are made largely on an ad hoc basis rather than being broadly available. This is what Amendment 205 seeks to correct. The NHS is a great British institution. The clue is in the name: it is a national health service. Therefore, should access not apply right across the UK?
I urge the Government to accept these amendments. I cannot see why they would not, as they will not only ensure better co-ordinated healthcare throughout our United Kingdom; they will ensure that patient care for all our citizens, wherever they live, is given due consideration, and they will clearly illustrate the importance that the UK Government place on the well- being of people right across the UK. I look forward to the response from the Minister.

Baroness Finlay of Llandaff: I am most grateful to the noble Baroness, Lady Morgan, for tabling these amendments and starting this debate, because these three amendments are very different.
I welcome Amendment 17. Of course we should consider the devolved Administrations because of all the cross-border flows. As we have just heard, people move around the UK. We have a lot of patients from Wales—I should declare my interests; I will not list them all in Hansard, but I have various roles in Wales and have done various things with IT in Wales as well—who routinely go into England from across north Wales; and in south and mid-Wales, they go across to Hereford and Shropshire. So I say to the Government, please make sure that you do always consider the impact.
We need patient-based clinical information that flows between different systems in a timely manner. The noble Baroness, Lady Fraser of Craigmaddie, referred to patient-held records. I hate to disappoint, but we did a quite extensive research project on them and found that there were all kinds of problems with them, one of the main ones being that, when the patient turned up in ED, they inevitably did not have their record with them—or they did not want things written in it in case somebody else in the family saw them, and so on and so on.
Here, I must have a bit of a boast about Wales because we are years ahead of other places, certainly of England. I think Scotland is also ahead of England here. For over six years now we have had a shared care record through the Welsh Clinical Portal. That means that wherever you are in Wales your primary and secondary care data can be instantly accessed through the shared portal. That extends out into voluntary  sector providers such as hospices, which have all been provided with secure routers. There are over 30,000 users and this extends also into the ambulance service and the out-of-hours advisory service.
This is not read-only. This has read and write functionality and is extremely secure. There have been very few breaches and there are very clear codes to make sure that people do not inappropriately access a record. On the system there are over 30 million care records, 200 million test results and over 3 million GP summary records. There has been backloading of historic records, including the all-Wales cancer records systems, of which there were—I would have to say—two and a bit because there were two main ones and another one. The GPs have all come on board as well to simplify their systems to bring it all in. That figure of over 3 million GP summary records is important because I remind noble Lords that the population of Wales is just over 3 million. That gives an idea of the completeness of the system.
When a patient is offered treatment available in England but not in Wales there is another issue: cost recovery. This is negotiated on an individual basis. A difficulty arises when the suggestion is that English demands are imposed on the devolved responsibilities through imposed interoperability of data and collection of healthcare statistics across the UK. This undermines the devolution settlement and, sadly, opens the door to politicising the use of official statistics. I will go into that now.
Amendment 301 would specify binding data standards across the UK. However, because health is a devolved responsibility, there is a problem if the Secretary of State is able to make decisions affecting Wales that are outside the reserved areas; decisions can be made in reserved areas, such as over human tissue. It is not acceptable for the Secretary of State to, in effect, grab powers or impose into a devolved area. This can be done on a voluntary basis by UK health performance outcomes observatories, with negotiated arrangements for data sharing on the basis of mutual consent. However, I suggest that it should not be in primary legislation. There is already a concordat on statistics that sets out how the four nations will work together to produce comparable statistics and the code of practice. For statistics, this ensures that their content, timing and method are free from political interference.
The second problem is that data interoperability is much broader than statistics on performance and outcomes. I have already illustrated that there is benefit to patients from data interoperability at the health record level. We have it for the whole of Wales and it works incredibly well. However, we need data interoperability between England and Wales, as has already been outlined, because of the problems for individuals where there is relatively high traffic across the border, covering cross-border referrals specific to patient care. There is already a project to address this with NHSX and all the trusts that border Wales, making good progress on a voluntary co-operation basis, so direction from the Secretary of State is not needed. I gather too that NHSX is a bit behind, and an audit showed that 37 out of 42 ICBs had a shared basic care record in place—the remaining five did not  —but there was not adequate interregional connectivity. This connectivity has been an ambition since 1990 so there is a serious lag in making this happen, for a variety of reasons.
Amendment 205 reveals the funding differentials between the four nations, in large part because of the Barnett formula, which works against Wales and does not solve the problem. Wales has a higher burden of illness, mainly because of demography. We have a more elderly population. In terms of equality, we are relatively less prosperous, which drives social determinants, as we have already discussed today, and different behaviours.
An additional factor is that people want to retire to Wales. We welcome them. They come for positive reasons. Having been in England while economically active with relatively little healthcare need, they come to Wales, and they age and need more health and care. I was interested to see that the examples given related to degenerative disease; hips and knees give out as people get older. So, we have a bigger burden, but we do not have the funding, and that is a problem.
The need/demand burden is objectively different, and Barnett has never been a needs-based formula, yet funding determines what can and cannot be provided. Workforce supply depends on UK training quotas, and higher training placements across the UK. Much of this is outside of Wales’s control. To give just one specific example: in critical care, there are shortages in the allied health professions. They are everywhere, but they are worse in Wales—well below the recommended levels for critical care in the UK. Without the money to employ the staff and without the supply of those professionals, we are stuck. We would gladly employ them if we could. The ability to manage patients will not be improved until we make sure that the funding is looked at, addresses need and recognises some of these demographic differences.
I strongly welcome Amendment 17 and say “Please take notice of the devolved nations, even though the populations are smaller”, but there are, I am sorry to say, real problems with Amendments 301 and 205, and I hope the Government will come up with a solution and make sure that we have the health service that Aneurin Bevan wanted to instigate, which was for everybody at the point of need.

Lord Lansley: My Lords, I will intervene briefly, if I may, to support my noble friend in her Amendment 17. I am glad to follow the noble Baroness, Lady Finlay of Llandaff. I will not follow her in discussing the financial settlements between NHS England and NHS Wales; there is a lot to that. But I confess that I rather share her view that it would be a stretch too far for us to seek to legislate in this Bill for matters that are the subject of devolved powers for the parliaments in Wales and Scotland, even though the issues are very interesting and the points that were made, not least by my noble friend Lady Fraser, were perfectly sensible and rational objectives.
I will confine myself to Amendment 17 and say there are good reasons why my noble friend and the Government might adopt it. It seeks to amend what is presently Section 13O of the National Health Service Act.  The differences are important. First, if one looks at Section 13O as it stands, it requires the board—NHS England for these purposes—to
“have regard to the likely impact of those decisions on the provision of health services to persons who reside in an area of Wales or Scotland that is close to the border with England.”
It is perfectly reasonable that it should do that, but that is not, as the debate has illustrated, the extent of the issue.
Speaking entirely personally, my late father-in-law was resident in Anglesey. He needed cancer services, so—perfectly sensibly—he went to Clatterbridge in the Wirral. My noble friend Lord Hunt is of course a former Secretary of State for Wales. He will be very familiar with the way in which services between north Wales and Cheshire, which he formerly represented, were provided. That is one straightforward example.
A number of noble Lords will recall the debate when I was Secretary of State about paediatric congenital heart services. In north Wales, they were provided in Liverpool, if I remember correctly. In south Wales, they were provided in Bristol. Those are one or two aspects of a necessary relationship for specialised services between different parts of the United Kingdom. At the border, there is a relationship in day-to-day healthcare services. There is an arrangement for that, and we do not need to interfere with it in this legislation. Shropshire CCG presently runs it on behalf of NHS England.
NHS England and NHS Wales have a statement of values and principles which, as far as I could see on looking it up, was last renewed in 2018. I think it is due for renewal. Basically, it relates to about 21,000 patients from England who are registered with Welsh GPs. About 15,000 patients resident in Wales are registered with English GPs. There is a transfer and a netting off of costs between them of about £6 million, and arrangements exist for referrals between the two countries. So we do not need to interfere with any of that, but the legislation needs to cover in particular this first point: that we are concerned not only with those who live in the areas bordering England and Wales; we are concerned with people in England and in Wales more generally, as well as with people elsewhere in Scotland and Northern Ireland.
The second point is that the present drafting excludes Northern Ireland. Clearly, there should be a role for NHS England. It should be prepared to consider its functions in relation to the provision of services—obviously where required and requested—by the Administration in Northern Ireland.
Finally, the drafting of Amendment 17 rather sensibly says not only that one should consider the impact on people living in Wales, Scotland and Northern Ireland but that one should think about the provision and delivery of additional services for people living in those areas. Amendment 17 makes this clear in 1(b):
“(b) services provided in England for the purposes of”
the health services in Wales, Northern Ireland and Scotland. In so far as any of those Administrations were to make a request or, under the concordat that exists, to look for support for services, that is something that NHS England would have the necessary legislative cover to support.
I appreciate drafting, if I may say so, and even at this stage my noble friend has drafted a very good amendment which I am rather hopeful that my noble friend on the Front Bench will also commend.

Baroness Bennett of Manor Castle: My Lords, in very clearly introducing these amendments, the noble Baroness, Lady Morgan, said that this group might not get feisty. I hope that we can manage to be very civil and calm in tone. None the less, there is a degree of disagreement—to which I am going to contribute.
In concluding her remarks, the noble Baroness said that this is a UK institution, embodying UK values. That seems to deny the reality of devolution. It is entirely possible that at least one of these countries could be an entirely separate nation very soon. That is the practical reality.
Once again, I was struck by the similarity with the climate change debate we had earlier. Sometimes people say, “Well, the scientists will tell us what to do about climate change”. Of course, this cannot be true, because how you get to 1.5 degrees involves a huge number of political choices around the allocation of resources. Similarly with health, many different routes and choices are involved in the effort to produce as healthy as society as we can. Whose health are you talking about? These are all political choices.
The noble Baroness, Lady Fraser, said that this was about data, not delivery. Of course, we know that very often what is delivered is what is measured, and if you choose to measure different things, maybe that is because you are seeking to deliver different things.
Like other speakers, I do not have any particular problem with Amendment 17, but I do with Amendment 205 and, in particular, Amendment 301, which says:
“The Secretary of State may … specify binding data interoperability”
and
“Scottish Ministers, Welsh Ministers and Northern Ireland Ministers must arrange for the information”.
I do not speak for the Scottish Government—albeit that they have some Green elements—but I would be surprised if they accepted that kind of wording. I do not wish to redraft on my feet but, if the Minister were looking to redraft, I suspect that something like a direction to the Secretary of State to “work with the Scottish, Welsh and Northern Ireland Ministers to agree” would definitely be preferable.
However, I agree with the noble Baroness, Lady Finlay, who gave us some very detailed and informed comment, that the best way to achieve this is by institutions at an operational level working together to find ways to link things up. If we take the example given by the noble Baroness, Lady Fraser, about her daughter’s situation, we can all be very annoyed that that apparently rather simple situation has not been sorted out. But I do not think drafting law in your Lordships’ Chamber is the way to sort that problem out. That needs to be at a very different level, and it needs to be sorted out as soon as possible.

Baroness Walmsley: My Lords, I support Amendment 17 from the noble Baroness, Lady Morgan. There are of course different waiting-list lengths in the  different Administrations, but I take the point made by the noble Baroness, Lady Finlay, about fair funding. She makes a very good point about Wales.
I too have had experiences like those of the daughter of the noble Baroness, Lady Fraser, over my Covid vaccination status, because I live in Wales and the NHS app in Wales did not seem to speak to the other one. But, as the noble Baroness, Lady Bennett, said, that is something that needs sorting out at a different level.
As I said, I live very near the border in Wales, so I am acutely aware from personal experience that the nature, quality and resources of healthcare in England affect the people of the devolved Administrations. I accept what the noble Lord, Lord Lansley, said: it is not just about people near the border—Anglesey is not at all near the border—but in day-to-day working it affects people near the border very frequently.
These are of course devolved matters, but in their practical, day-to-day operation the borders are what people call “leaky”—in other words, people travel both ways for work, school, shopping, leisure and indeed health services. So, particularly in the border areas, it makes a lot of sense to do what the noble Baroness, Lady Finlay, said happens all the time: for GPs to be able to refer patients for a particular service to or from the devolved nations. That is why anything that affects the provision and quality of services in England also affects Welsh and Scottish people in particular. I suspect it is slightly less the case for people in Northern Ireland, although waiting lists there are particularly concerning.
So this is particularly important in relation to the location of specialist hubs, because the border areas of both Wales and Scotland are very rural and the distances and transport difficulties to their own hospitals can be long and difficult—even more so if the patients have to cross the border. We need to ensure that anything done in the Bill makes cross-referral able to continue as easily as it does at the moment.
What discussions have taken place with the devolved Administrations about the Bill? Are there any aspects of it that are still waiting for the agreement of the Governments of Wales, Scotland or Northern Ireland?

Baroness Thornton: My Lords, I am very grateful to the noble Baroness, Lady Walmsley, because she has helped me to clarify my thinking about this group of amendments. Basically, they have good intentions and they make good points about the things that need to happen, but I am not absolutely certain they need to be in the Bill. I am also particularly grateful to the noble Baroness, Lady Finlay, for her very well-informed contribution about what actually goes on. There are of course problems in relationships between the devolved nations and NHS England, some of which are down to not being very well organised, some of which are down to arrogance on the part of the bigger ones, and some of which are down to the funding not actually being available—and some of them might be politically motivated too.
Amendment 17 opens some new thinking on the subject of integration, and accepts that devolution has given us different systems for care in Wales, Northern  Ireland and Scotland, but seeks to ensure that what is done in one part of the UK—that is, England—does not adversely impact on other parts. The intention to bring collaboration between the nations is, of course, commendable.
I note that Amendment 205 places some requirements such that
“Welsh Ministers, Scottish Ministers and a Northern Ireland department must make regulations providing that the choices available to patients in England by virtue of regulations under section 6E(1A) or (1B) of the National Health Service Act 2006 (inserted by section 69 of this Act) are available to patients for whom they have responsibility.”
Again, we can understand the need for consistency, but I am unclear about how that will play out against the devolved nature of healthcare—so I think the case will have to be made out for that and, indeed, why that would be included in the legislation.
In a similar fashion, Amendment 301 looks to establish interoperability around the use of data across the whole UK. Again, that is a wholly worthwhile intention, and one that I would hope that the various authorities could collectively work on and agree. Once more, what the role is for primary legislation to address this point is not entirely clear, and I welcome the discussion. I look forward to hearing what the Minister has to say.

Earl Howe: My Lords, I begin by thanking my noble friend Lady Morgan for raising these important matters both via this Committee and by engaging—as I understand she has recently—with my honourable friend the Minister of State for Health. I am also grateful to all other noble Lords who have spoken so powerfully and knowledgably on these issues.
There is no escaping one overarching reality in this policy area, to which the noble Baroness, Lady Thornton, has just alluded. As a Government of the whole United Kingdom, Ministers are responsible for all people of the UK; that is a given. However, while the core principles of the NHS are shared across all parts of the United Kingdom, it is the devolved Governments in Scotland, Wales and Northern Ireland who are responsible for developing their own health policies. Health is largely a devolved matter in the UK, and the commissioning and provision of health services for people in Scotland, Wales or Northern Ireland will continue to be a matter for the devolved Governments.
It will not surprise my noble friend to know that the UK Government continue to respect existing devolution settlements, so our aim is close collaboration with the devolved Administrations to deliver the best outcomes for the people across the four nations. This means that, while we are sympathetic to the spirit of these amendments, I am afraid that we cannot accept them.
I shall address the detailed issues. On Amendment 17, I agree with my noble friend that there is more we can do to align our healthcare for the good of patients across the United Kingdom. We are already exploring several projects to support the NHS to work more closely across the UK, and this includes refreshing the current memoranda of understanding between all four Governments and working with the Office for National Statistics to establish a number of UK-wide datasets. Steps like that will improve transparency and collaboration  for the good of all patients across the UK. We do not believe that these steps require primary legislation, but we will keep that question under review. We will also continue to work with NHS England to ensure that a number of groups that it currently hosts, such as the rare diseases advisory group, and their specialised commissioning processes, also meet the relevant needs of the devolved Administrations.
Turning to Amendment 205, we know that choice of healthcare is an important right for patients across the UK. The NHS Constitution for England, for example, enshrines the patient’s right to informed choice. We will be preserving the important right for patients in England to choose their first elective outpatient appointment, GP and GP practice through regulations made under powers provided by the Bill. NHS England works closely with the devolved Governments, including on commissioning and ensuring access to specialised services. Requests for patients to have treatment in other nations are generally to secure continuity of care, to provide care close to patients’ support mechanisms, or because of specialist expertise.
The health services in Scotland, Wales, and Northern Ireland already have the power to contract with any NHS provider in England. As my noble friend Lord Lansley rightly pointed out, they already have in place arrangements for commissioning specialised services from English providers, including cross-border agreements, referral schemes and service-level agreements. Taking further steps, as suggested in this amendment, would place a significant burden on a smaller number of providers, particularly those along borders, with consequences for the smooth running of those health systems. From a legal perspective, such a change would be a significant impingement on a devolved competence and would require the consent of the devolved legislatures. Of course, patients matter most, but such a change would also be unlikely to greatly benefit them, since they are already served by existing arrangements.
Amendment 301 deals with data interoperability. The UK Government are committed to working with officials across the devolved Administrations to explore the benefits that healthcare data can provide while working collaboratively to respect the devolved nature of this work. As in other areas, we are looking at ways to improve collaboration on data matters and address issues with data sharing. There are commitments within the data strategy for health and social care to work across central government and the devolved Administrations to improve appropriate data linkage, thus supporting people’s health care outcomes. This builds on the work of units such as the Joint Biosecurity Centre, and the newly established UK Health Security Agency.
That work will help us to collaborate to solve public health issues, improve disease surveillance and overcome any behavioural or structural obstacles to appropriate data sharing across our respective health and social care systems. In addition, we are speaking to the Office for National Statistics about collecting data on performance and outcomes across the UK. We are pursuing this with it, working in concert with the devolved Administrations. The ONS has assured us that it does not need additional powers to gather such data.
The problems encountered by the daughter of my noble friend Lady Fraser in proving her vaccination status are being actively addressed on both sides of the border. I must concede that the problems are not fully resolved yet, but understand that a Covid status pass from Wales, Scotland or Northern Ireland will be recognised in England and vice versa.

Lord Bradley: My Lords, I am sorry to interrupt, but I have been meaning to ask this question for a while. Will that also apply to students who currently study abroad and had their first vaccinations abroad, and who then come back to work in their home country? Will that be connected to the NHS app as well?

Earl Howe: Rather than give a wrong answer to the Committee, I had better take advice on that and write to the noble Lord, if he will allow it.
I say to the noble Baroness, Lady Walmsley, that if we look at this area in general, we are clear that we must and will continue to work closely with the devolved Administrations to ensure a fully interoperable, UK-wide approach to healthcare, including in relation to the provisions in this Bill.
It is worth adding that the devolved Administrations already have powers in legislation under Section 255 of the Health and Social Care Act 2012 to request NHS Digital to collect and analyse data, so they have that ability if they wish to exercise it. I am very grateful for my noble friend’s interest in this important area. I assure her that we will continue to keep listening to ways in which we can make the NHS work for all four nations of our union. It is vital that we do so and implicit in the collaborative processes we are engaged in. However, for the reasons I have set out, I ask my noble friend to understand why I am unable to accept this amendment.

Baroness Morgan of Cotes: I thank my noble friend very much for his response. Although this has been a short debate, it has been a very good one. It has certainly been very helpful in noble Lords on all sides sharing their experiences and thoughts. It has raised some important issues and some comments on drafting. I am grateful to noble Lords for them. It has also enabled your Lordships to share some practical experiences, not least about the NHS Covid app. It sounds as if it is moving towards a resolution.
I was slightly amused that some of those who said that these issues do not need to be addressed in the Bill are often those who say that other issues need to be addressed in primary legislation so, when we are talking about consistency, we all need to think about that.
I am very grateful to my noble friend for saying that he agrees that more needs to be done and is being done to align healthcare across the United Kingdom and for stressing the importance of collaboration. I will, of course, withdraw this amendment, but the amendments in this group raise important issues and I hope that discussions can continue. As the noble Baroness, Lady Walmsley, I think, said, this is about practical, positive treatment and outcomes for patients, which is what we all want to see regardless of where they live.
Amendment 17 withdrawn.
Clause 6 agreed.

  
Clause 7: Support and assistance by NHS England

Amendment 18

Baroness Thornton: Moved by Baroness Thornton
18: Clause 7, page 4, line 18, at end insert—“(5) Assistance or support provided under this section to a person or organisation which is not an NHS body or representative of an NHS body, may only be provided after consultation with the relevant integrated care board and integrated care partnership.”Member’s explanatory statementThis provides that the relevant ICB and ICP must be consulted before assistance is provided to bodies other than NHS bodies. It aims to ensure a transparent process where private providers are provided with assistance.

Baroness Thornton: My Lords, I will address the amendments in what is now group 4, commencing with Amendment 18 in my name, which address the various ways in which the board of an ICB should be constituted. I thank the noble Lords who have supported the amendments in my name and will speak also to Amendments 28 and 37.
Amendment 18 covers who should be on the board and, crucially, who should not. These amendments are about the governance of ICBs. They are going to be very powerful bodies—they are already operating in a shadow way, as it were—which will allocate hundreds of millions of pounds of public funds on our behalf. The question is about who should have a seat at the table where the decisions are taken. We should perhaps begin with who should not be on an ICB. There appears to be agreement that private sector interests should not be permitted, so I see no point in repeating the debates that took place in the Commons because that principle has already been settled. However, as ever, the devil is in the detail of how that translates into legislation and the ICB constitutions. It is my belief that what is in the Bill so far is not strong enough.
The objective is that private providers cannot have any part in decisions about how NHS resources are allocated or how contracts are placed. In my other amendments, I have extended the scope of this to ban GPs with APMS contracts, as they are definitely private sector interests. How someone from a social enterprise or the voluntary sector might be regarded is an issue to address sensibly, and I very much welcome that the Minister has said on several occasions that he believes that a margin of flexibility will be needed to make that happen. We all know that there is a single example of someone from Virgin Care being on a non-statutory non-decision-making ICS, one out of the 42 ICBs and one person on a body with 20-odd other members. That is still one too many. It is the principle that matters.
Private providers are bound essentially and legally to be addressing shareholder value, which is absolutely right and as it should be for their particular business interests, but they are not the values that underpin the NHS, which is absolutely not about striving for profit and shareholder value in any way. That is not to say  that the NHS at every level should not strive for value for taxpayers’ money and effectiveness, but the best service for patients and communities is surely the underpinning objective of our NHS and it should be that for ICBs. Nor is it saying that the NHS should not be commissioning or working with a variety of providers, but we need to safeguard those values and the social value that underpin the NHS.
In the Commons this has been debated and Ministers are on the record about their intention not to have private providers represented. Sadly, some of us are still sceptical. This is particularly so when one looks at the easing of the 2012 commissioning and procurement regime. I await with interest the Minister’s reply on this matter. In making appointments to ICBs we are clear that there should be some kind of test so that if someone has something in their background which a reasonable person might think makes them unreasonably favourable or disposed to the use of private providers within the NHS, then they have no role on an ICB. I suspect that one might have to see, when the Bill finally takes effect as an Act, that those tests might be brought to bear on some of the ICS/ICB chairs and non-executive directors who may fail it.
The ICBs have similar duties to the CCGs they replace, at least on paper, but the board of an ICB will be very different from the CCG GPs and sometimes, it has to be said, the rather ad hoc arrangements that existed there. ICBs will be much closer to the unitary board model of trusts, FTs and the PCTs of recent memory. We agree with the intention of more effective commissioning of health services in the new era of co-operation and collaboration and with better integration with related services, so there should be a new kind of board made up of fewer NHS insiders and more who may have a wider perspective and fit better into the new model and the aspirations of the Bill.
We have had what feels like a dozen different ways of making commissioning work, and I have been directly involved in some. My observation is that as soon as they look like they are starting to work, they get reorganised. The trouble has always been the split between commissioners and providers, which some may say is essentially bogus. Both bits are still core NHS, and the big trusts have massive influence because they are massive. There is no democratic accountability, and the big providers had all the clout, not the commissioners. The NHS commissioning operation is often in splendid isolation from the rest of the public services, disconnected even from social care, to say nothing of where primary and community care and public health come in. This Bill aspires to be different, so we need to look at how it is served differently by the ICBs.
There has been some pretence that this will all change under the Bill, just as there has been for previous ones on commissioning. ICBs are given flexibilities and can build place-based sublevels, but the reality is that, as they are constructed at the moment, they are the same old NHS cartels. They have all the freedom they are allowed, but they may ultimately be powerless. The public will have as much idea about what ICBs do as they did about CCGs, and we all remember the marches to save our PCTs in the distant past. Just to make this clear, vested interests  get a place in the ICB as of right but the public, patients and staff are not given that honour and responsibility. That is what part of these amendments does. Amendment 37, in my name and that of others, sets out our view about which voices are most important, and it breaks the mould of NHS appointing.
I divert briefly to say that elsewhere we will discuss more about how those appointments are made. Our view is that some independent appointments commission ought to make a comeback. I took great encouragement from the comments of the noble Earl, Lord Howe, on Tuesday, which helped in this regard. But there is still far too much control from the top and far too little say from the bottom on all the appointments that will be made under the Bill. Amendment 37 at least offers a way to have some diversity and possibility to challenge the interests that dominate the NHS.
Surely nobody who looks at what the amendments suggest would argue that these interests do not have a right to some voice. The public, patients, staff, social care, public health, mental health—which of these can be safely ignored and which has no part to play? We know the Minister in the Commons gave a minimalist defence in the interests of the new mantra of flexibility. He rightly said that boards should be of a manageable size and that ICBs should have some flexibility—as much as NHS England would allow—to add others to the board, beyond the minimum. The NHS actually has to do what it is told and, unless a more stringent requirement is put in the legislation, it will do what it has always been allowed to do. If we really want a better care system and some change to make organisational upheaval worthwhile, let us have a go at doing something different, with a wider group of voices to be heard and take decisions.
Our Amendment 37 deals with appointing key non-executive board members to represent interests, but within a unitary board. On Tuesday, colleagues pointed out that all board members share collective responsibility, which is a tried and tested model, but we need a discussion about this. I can see from the amendments in this group that other noble Lords have views—my noble friend Lord Bradley and the noble Baroness, Lady Finlay, for example—but our amendments and others in the group, if we discuss them together, would make for a better balanced board, which does not necessarily have to be a larger board. I hope the Minister will consider these submissions carefully. I beg to move.

Baroness Garden of Frognal: My Lords, the noble Baroness, Lady Masham of Ilton, is taking part remotely. I invite the noble Baroness to speak.

Baroness Masham of Ilton: My Lords, I want to support the proposed new paragraph (h) in Amendment 37, which says,
“at least one member appointed to represent the voice of patients and carers in the integrated care board’s area.”
The patient’s voice should be heard throughout the Bill. What is the National Health Service for if not patients? Patients should be involved in planning, ensuring that patients’ and carers’ views continue to be  represented. Their experience should be collected. They, with their carers, are the people who know what good, safe care is and what poor results are. I hope the patient’s voice will be involved. I am pleased that many Members already stated this in amendments last Tuesday. I hope the Government agree, and I look forward to hearing from the Minister.

Lord Bradley: My Lords, I speak to my Amendment 38 and declare my health interests in the register, particularly as a trustee of the Centre for Mental Health and an honorary fellow of the Royal College of Speech and Language Therapists.
This amendment is short and simple. As its explanatory statement makes clear, it merely adds to the list of requirements for membership of an integrated care board that must be included in the ICB constitution. I believe it is essential to have a representative of mental health trusts for each ICB area, and therefore on the ICB, as it is the key strategic body for, among other things, healthcare commissioning, planning priorities and resource allocation for a local area.
The broad context of my amendment is to ensure that what progress has been made—and there has been progress—regarding the concept of parity of esteem between mental and physical health, and crucially the allocation of resources to mental health, is not lost in the new structure of the integrated care boards.
We have already had some powerful and compelling debate around the concept of parity of esteem, which I will not repeat today, but suffice it to say that, through this Bill, we must not lose the fact that Section 1 of the Health and Social Care Act 2012 enshrined in law equivalent duties on the Secretary of State for Health in relation to the improvement of physical and mental health services, and that, since 2013, the NHS Constitution for England has contained a commitment
“to improve, prevent, diagnose and treat both physical and mental health problems with equal regard.”
Obviously, this overall context is much broader than my amendment, but it has and will form the backdrop to many of our debates in the coming weeks. However, as a crucial step, and to secure that the commitments to mental health services are honoured, we must ensure the most appropriate and relevant membership of integrated—I stress “integrated”—care boards.
That is why I also support other amendments in this group, particularly Amendment 37 in the names of my noble friend Lady Thornton and others, in which proposed new paragraph (d) mirrors my amendment but also includes, as we have heard, directors of public health and social care providers. They must be included. Amendment 39 proposes an expert in learning disabilities and autism, which I strongly support. I look forward to hearing the noble Baroness, Lady Hollins, who I have tremendous respect for, speak to that amendment. It also must be accepted. Further, I have added my name to Amendment 40 in the name of the noble Baroness, Lady Finlay, to include allied health professionals. I give a particular mention to speech and language therapists. Along with other allied health  professionals, they will continue to play an important role, as the Government have recognised, in delivering the NHS long-term plan.
All these bodies are critical parts of delivering along the various pathways for mental health services, from early intervention and prevention to the most specialised care, and include the interface with the criminal justice system, such as liaison and diversion services. Therefore, it is essential that each of these bodies, and others, has a seat at the board table, and that, specifically, mental health trusts are statutorily included, as my amendment proposes.
If we take my own home area, Greater Manchester, as an example, there are essentially three mental health provider trusts covering the ICB area. I am sure they could agree who should serve on the board and ensure that the interests of mental health services are heard loud and clear. Without their voice, there is a real danger that the very powerful interests of acute trusts, principally delivering physical health services, will dominate the agenda, possibly undermining commitments on parity of esteem and skewing decisions on resource allocations —both revenue and capital—away from investment in local mental health services.
The Minister may suggest that such prescription is not required or that guidance will be sufficient to persuade ICBs to including mental health trusts on their boards. I have no doubt that the chair-designate in Greater Manchester, Sir Richard Leese, fully understands the imperative to include them on the board, but this is not good enough. This requirement must be underpinned by statute, otherwise there could be a lack of consistency across the 42 ICB areas that undermines equality of access to mental health services and further limits transparency and accountability to local people for decisions that will be taken on their behalf in respect of their mental health and well-being.
I feel sure that the Government will recognise this, and I look forward to a positive response not only to my Amendment 38 but to other amendments in this group that aim to protect the interests of mental health services across the country.

Baroness Hollins: My Lords, it is a pleasure to follow the noble Lord, Lord Bradley, and I support those amendments with respect to mental health. My Amendments 27 and 39 would provide for the addition of an expert in learning disability and autism on each integrated care board and ensure that the learning disability and autism lead was a person with knowledge and understanding of what good health and support look like for people with a learning disability and for autistic people.
As a starting point, this proposal has already been pledged by the Government in both the NHS long-term plan and the autism strategy, the latter stating:
“We also expect that all Integrated Care Boards, which will be established by the proposed Health and Care Bill, will focus on autism and learning disabilities at the highest level, for example by having a named executive lead for autism and learning disability.”
The reason for the Government’s firm commitment is that people with a learning disability and autistic people are among those who stand to benefit most  from the integrated approach that the Bill seeks to implement. These are people whose needs frequently span health and social care systems. They are one of the largest recipient groups in terms of cost of health and social care provision and therefore a cohort with one of the greatest stakes in the effective integration of these two systems.
People with a learning disability experience huge health inequalities—very relevant to discussion on the first group of amendments today. On average, the life expectancy of men and women with a learning disability is 14 and 18 years shorter than for the general population respectively. Thirty-eight per cent of people with a learning disability die from an avoidable cause as against only 9% in the comparison population. These inequalities have been hugely exacerbated during the pandemic, with death rates of up to six times higher than among the general population, according to Public Health England. People with Down’s syndrome were identified as being at as high a risk as the over-80s. Yet they have had inappropriate DNACPRs put on their hospital records without their consent and had catastrophic reductions in care and support during the past two years, which will take years to recover from. There has been much greater reliance on family carers, who are too often dismissed as difficult by poorly trained health and social care decision-makers.
It is not learning disability and autism that are the cause; it is the situation that they are in as a result of ineffective plans and ineffective responses to their needs. Learning disability and autism, as well as foetal alcohol spectrum disorder—a much underdiagnosed and poorly understood condition but related to the groups I am speaking about—are lifelong states of being, but they are unequal states of being. Having a learning disability or being an autistic person is not like having cancer. People with learning disabilities and autistic people also get cancer; they also have a much higher prevalence of mental health problems.
The work I am overseeing for the Department of Health and Social Care places the major responsibility for inappropriate and lengthy detentions in long-term segregation under the Mental Health Act at the door of commissioners. It is a commissioning failure in the main. Some commissioners have relied on the availability of crisis admissions rather than collaborating to develop essential community services, including housing and skill support, social prescribing of meaningful activities and other innovative wellness approaches.
This is an urgent appeal to the Government to clearly signal a requirement for competent and accountable commissioning for people with a learning disability and autistic people. There is a lot of money being wasted at the moment through very poor commissioning. Please can we get it right this time?

Baroness Bakewell: My Lords, before I address my Amendment 28, giving my support to my noble friend Lady Thornton, I wish to endorse the other amendments that are calling for representatives of particular groups—we just heard mention of two. I particularly endorse all those, especially as I am taking rather an oblique approach to this debate, which is not reflected in the other amendments.
Last year, there was a report in America that, increasingly, hospitals there were closing. The report said that hospitals were seen as businesses; a fifth of hospitals in America are run for profit, and globally, private equity investment in healthcare has tripled since 2015. In 2019, some $60 billion were spent on acquisitions. Globally, that includes—indeed, targets—us and the NHS. Where does that affect us? Increasing inroads are being made into the National Health Service by Centene and its subsidiary Operose, which now own 70 surgeries around this country. From Leeds to Luton, from Doncaster to Newport Pagnell, from Nottingham to Southend and many more, Centene now owns and runs for profit surgeries formerly owned and run by NHS doctors. It is now the biggest single provider of GP surgeries in this country. It has further designs on the existing fabric of the NHS, seeking to have its representatives sitting on the boards of CCGs, making decisions about the deployment of NHS funding. This is a direction of travel that needs to be monitored and checked. Safeguards must be written into the Bill against this takeover.
Why does it matter, just as long as patients have good and free treatment at the point of need? What is the reputation of Centene in America? It is not good. Indeed, it is regularly embroiled in lawsuits from either patients or shareholders, and the sums are not small. In June last year, Centene had to pay a fine of $88 million to the state of Ohio for overcharging on its Medicare department. This is one of many. Since 2000, there have been 174 recorded penalties for contract-related offences against Centene and its subsidiaries. That enterprise is now active in this country and targeting our NHS. It is not a fit company to be part of our health service. I therefore ask the Minister for safeguards to be written into the Bill against such people being represented on our boards. When I raised this at Second Reading, the Minister replied that there was no chance of us selling the NHS. We do not need to: they are buying us.

Lord Davies of Brixton: My Lords, I will not detain the Committee in speaking to my Amendment 30. In truth, I am speaking in favour of my noble friend Lady Thornton’s Amendment 29. I could claim that my amendment has the virtue of being shorter but perhaps brevity is not always a virtue. Amendment 29 also makes the important point that it is the sub-committees and committees of the ICBs that will be crucial. The substantive point is that the Government have to accept that the amendment agreed in the Commons is totally inadequate. It depends on matters of judgment. We want a clear specification of who is appropriate to be a member of those bodies.

Baroness Bennett of Manor Castle: My Lords, it is my pleasure to support all the amendments in this group, so ably introduced by the noble Baroness, Lady Thornton. I thank her for tabling this amendment and Amendment 28, to which I was pleased to attach my name.
I agree with pretty well everything that has been said but want particularly to highlight the contribution of the noble Baroness, Lady Hollins. As she was talking, I was thinking about testimony that I heard  earlier this week at the All-Party Parliamentary Group for Art, Craft and Design in Education. A teacher was saying that if their educational provision caters to the most vulnerable and disadvantaged pupil in their school, that means that it is catering the best for everyone. It might be thought that having a representative for the interests of those with autism and learning difficulties will affect the care that they receive but it would actually greatly improve the care that everyone would receive. That is not often adequately understood.
As the noble Baroness, Lady Thornton, said in her introduction, there are really two sub-groups here. Going from consideration of Amendment 18 to Amendment 30, we are essentially talking about, as the noble Baroness, Lady Bakewell, was saying, the need to avoid corporate capture of our NHS, although the corporate sector has already won many battles and taken over a great deal of the NHS. If the need for profit is the way in which things are being run, care must suffer. Care is the second priority and that is an unavoidable fact. When one considers privatisation—I have later amendments that will address the care sector in particular—we see where this has been allowed to extend to extremes, whereby the private equity sector has taken over our care system at enormous cost to the quality of care for public and private pockets. The system is in a state of near-continual collapse. We have to make sure that ICBs do not go down the route that our care sector has already gone down.
I am thinking about this matter for Report. There is also a further issue whereby although these amendments address people’s current employment and roles, we also need to think about the revolving door situation, about which, I see from social media, the public are increasingly concerned. We see people flipping between the private and public sectors and taking the interests, direction of travel and thinking of one to the other—and not for positive purposes.
I am aware of the hour but I am looking at the second sub-group of amendments, Amendments 37 to 41, and at who should be there. The issue relates to my comments on the previous group. We cannot just say, in terms of managing the NHS, “Just leave it to the doctors and the experts. They know about care.” Of course they do in terms of running services but in making choices and allocations and in ensuring that the ICB meets the needs of its community, it is the community that knows what the needs are and should tell the medical people what needs to be delivered, and the shape of that delivery. The technical details will come down to the medical people.
It is therefore crucial that we do not see the ICBs as technocratic places for people with MBAs and doctors but that we should include trade unionists, patients and carers. Carers are particularly important because our current system does so poorly in meeting their needs and supporting them. We need bodies that truly serve to represent the community.

Lord Hunt of Wirral: My Lords, in declaring my interests as set out in the register, I want to press my noble friend the Minister on conflicts of interest.
Paragraph 8 of Schedule 2 to the Bill provides that local NHS trusts and GPs are to appoint members of the integrated care board. Organisations that provide  the bulk of NHS services will therefore be co-opted into the work of commissioning. It is currently the work of commissioners to hold providers to account, objectively determining whether they are best placed to provide a service and assessing their performance. The new integrated care boards must continue to perform that role.
Clause 14 introduces into the 2006 Act new Section 14Z30, subsection (4) of which provides, rightly:
“Each integrated care board must make arrangements for managing conflicts and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the board’s decision-making processes.”
Reference has already been made to amendments that seek to exclude individuals involved with independent healthcare provision from joining the ICBs. Does my noble friend the Minister agree that the membership of provider appointees on integrated care boards may at least risk creating a perception of a conflict of interest between the roles of those individuals on the board and any roles they may hold with provider organisations? How can the benefit of provider input into the work of an ICB be reconciled with the task of objectively assessing both the suitability and performance of providers? I believe that greater clarity from the very outset on the extent of the role that provider appointees will be expected to play will surely assist ICBs in developing robust governance arrangements, which would then enjoy public confidence.

Baroness Meacher: My Lords, I support Amendment 37. In so doing, I add my strong support to the comments of the noble Baronesses, Lady Bakewell and Lady Bennett.
Of course, the ICBs will be central to ensuring adequate funding and support, not only for the powerful acute health trusts and primary care but for the services that are historically underfunded. It is for these services that this amendment is particularly important. Before discussing these specific gaps in the Government’s vision for the new system, I want to stress that I am very concerned that we should not lose vital clinical leadership along with patient representation, which were the hallmarks of the CCG system. Of course, we want worker and carer representation but, in my experience, top medics are actually rather good at deciding how money should be allocated across services.
In my view, the absence of a public health representative from the shortlist of necessary ICB members in the Bill is an extraordinary oversight. This amendment seeks to put that right. ICSs are already in the process of developing their draft constitutions, which, while dependent on the final content of the Bill, provide a clear indication of their intent regarding clinical membership. It is particularly concerning that several ICSs have failed to include any role on their ICB for public health experts in their draft constitutions, with some failing to make any reference to public health at all. As the BMA points out in its briefing, this poses a significant risk to the role and prominence of public health within the work of those ICBs.
In relation to the importance of public health representation on ICBs, noble Lords should be aware of the impact of this on the vexed issue of drug addiction. Police services up and down the country are  recognising that criminalisation and imprisonment are entirely counterproductive in this field. These responses only limit the young person’s education and employment options and tie them into a life of drugs and crime, with appalling consequences for them but also for their communities. Police services are increasingly adopting diversion to treatment as a preferable response when an individual is found in possession of drugs, but drug treatment services have been cut over the past 10 years. ICBs will need to tackle this situation as a matter of urgency if the police are to be able to stem the tide of county lines and other highly damaging consequences of our counterproductive and, in my view, idiotic drug policies and failure to treat addiction as a mental health problem, which, of course, it is. These urgent issues will not be confronted unless public health is strongly represented on ICBs and other boards and committees in the new structure.
Another cri de coeur is for mental health, as others have said. Having chaired a mental health trust for many years, I am acutely conscious of the impact of bed shortages on very sick people and their families and of the very high threshold for child mental health services. There is no doubt that if we do not treat children with mental health problems, we will have adults with these kinds of problems throughout their lives. The country cannot afford to continue neglecting this important field. I support the other amendments in this group. The NHS has major long-term workforce shortages and other problems. If they are to be addressed adequately, the staff need representation, along with patients and carers.
I end with a plea to ensure, through membership of ICBs, ICSs and ICPs, that clinical leadership is retained within the NHS. On ICBs, this must include at least two primary care members, at least one clinical representative of secondary care, acute care and mental health and at least one qualified and registered public health consultant. I hope the Minister will tell the Committee whether he agrees with this approach to ICB membership.

Lord Patel: My Lord, I rise very briefly to support Amendment 37 in the name of the noble Baroness, Lady Thornton, to which I have added my name. She and the noble Baroness, Lady Meacher, have identified in detail why this is a key amendment that identifies the core representation that is required for ICB boards to function satisfactorily and develop strategies for population health in their area, and I strongly support it.

Baroness Tyler of Enfield: My Lords, I shall speak very briefly to Amendment 38 in the name of the noble Lord, Lord Bradley. I have huge sympathy with the intention behind this amendment. Everything that we have talked about so far on mental health has pointed to the fact that unless there is a strong mental health voice on ICBs, the whole issue of mental health funding and the priority it has will not get as strong a voice as it should. I recognise that some argue that we should not overspecify the membership of new bodies but should allow each integrated care system the flexibility to develop based on its own set of local relationships, and I do not overlook that point. However, my natural sympathy is that it is only too possible for mental  health concerns to be ignored when decisions are made about resource allocation and prioritisation without a strong mental health voice around the table.
However, I think I may have a way through this. We need to look back to the discussions we had on Tuesday about the overriding importance of mental health being explicitly mentioned in the triple aims. If such an aim were in place, I think we would be hard pushed to form an ICS or an ICB without mental health representation and we might be able to argue that it is not necessary, in those circumstances, to have it in the Bill. However, if that aim is not explicit, then the argument put forward by the noble Lord, Lord Bradley, is very strong indeed.

Bishop of London: My Lords, I rose on the first day of this Committee to speak to the membership of NHS boards. I rise today for a similar reason: I think it is very difficult to stipulate the membership of boards, just as the noble Baroness has said. However, as I said with NHS boards, I say with ICB boards that I think the voice of the patient is central. Along with my role as the Government’s Chief Nursing Officer, I was director of patient experience while I was in the Department of Health. As a nurse at that time, I believed I had a patient focus. However, I learned that my default was always as a professional and that the patient needs a voice and empowerment. While I recognise the clinical voice and would always want it on the NHS board and the ICB board, it does not replace the voice of the patient and the carer.
I recognise that on the first day in Committee the Minister was not inclined to accept the amendment that related to patient and carer representatives on the board. If he is not inclined to accept Amendment 37H, can he explain to us how the voice of carers is threaded through this Bill to ensure we appropriately meet their needs? At the end of the day, if we give them a voice, they design the services better. In the long term, it saves money as well as giving them agency. I believe that if the voice the patient is threaded through this Bill, it would answer the concerns of the noble Baronesses, Lady Masham and Lady Hollins, and the noble Lord, Lord Bradley, by ensuring that it is focused, whether on the needs of those with learning disabilities or mental ill-health or other groups.
I recognise the difficulty of outlining and detailing names in the Bill, but I would be interested to know from the Minister how the voice of patients and empowering them and giving them agency is threaded through this Bill.

Baroness Pitkeathley: My Lords, like the noble Baronesses who have spoken before me, I recognise the difficulty of being too specific about board membership, but I think that paragraph (h) in Amendment 37 in the name of my noble friend, to which the noble Lord, Lord Patel, has added his name, is wide enough to enable patients and carers to be represented. Indeed, given the Government’s commitment to the voice of patients and carers, I find it difficult to understand how they could not accept such an amendment. I know the Minister is extremely committed to that patient and carer voice.
I want to extend that a bit to making sure that we do not forget the vital contribution that charities and community organisations make to health and social care services through their well-documented ability to be innovative and flexible. Your Lordships know that in the course of the pandemic, they immediately operated better delivery mechanisms than the statutory sector was able to because they were able to be flexible. One million volunteers were recruited, and many people had experiences similar to mine, with people saying that it was only through the services of voluntary organisations and charities that they had any kind of support at all, particularly during the first few weeks of the pandemic.
When the Public Services Committee of your Lordships’ House did its inquiry into how public services had reacted to the pandemic, time and again we received examples of where charities were ignored by public service providers. Even if they were consulted at a later stage in planning, it was not to take account of their experience and skills but to assume they would co-operate in whatever role was doled out to them. That is not the way to make the best use of the untold amount of good will, experience and skill that exists in charities, especially in the areas of health and social care. This is a waste of scarce resources and must be recognised in the new structures as they are set out. There are many examples of where these partnerships work well, recognising the different skills on offer, and of where charities are treated as partners, but they must be involved in planning at the earliest stages and be supported financially if appropriate. They will always give a good return on resources.
The other area where charities make a significant contribution is in representing the patient and carer voice. Voluntary sector organisations are often the services that have most contact, especially with vulnerable people. Your Lordships will have endless examples of that. Much is made of how important the voice of the user, patient and carer is when planning or delivering the services. Co-production, co-design and the other buzzwords we hear all the time absolutely depend on being in touch with users and patients. Almost inevitably, the easiest way to access users and patients is through local or national charities which make users their focus, both in the planning of services and the governance of the organisation.
Proper involvement of users, patients and carers often throws up surprises, even pleasant ones, about money. If you really take the views of users and patients, you will often find that what they want from health and social care services is not what is being provided. They will often ask for less provision than we expect, so long as it actually meets their needs, not the needs estimated by the providers. This is a valuable fact when resources are short. It is one more important reason to forge partnerships with the voluntary sector when the memberships of ICBs and ICSs are being set up. Organisations in their areas should be considered as partners which have a great deal to contribute and will do so willingly and productively.

Baroness Finlay of Llandaff: I have two amendments in this group, so I will try to address them very briefly because of time. I am most grateful  to the noble Baroness, Lady Thornton, for the way that she introduced this and would like to return very briefly to the issue of public/private potential conflict when public money is being spent, because there is an issue of probity around that. Having shared corporate accountability for the delivery, functions and duties of the ICS could be in conflict with the legal duties of company directors, as has already been pointed out, and therefore creates problems.
I know that the Government recognised this in the other place, but their amendment seems to fall short in two respects. It leaves to the appointed chair of the board the decision on whether a person with interests in private healthcare is incorporated into an ICB. The difficulty is that it provides a condition that their interests in private healthcare could undermine the independence of the health service, but it is very unclear how that will actually be measured. I can see that it would be a fantastic area for legal argument that a precedent had been set in one area that was being worked against by the chair of another ICB. I think this needs to be clarified, because they will be dispensing public money and there are examples already where different decisions have been taken. I will not go into those now because of time.
I turn briefly to the reasons behind the amendments I have put down and declare that I am president of the Chartered Society of Physiotherapy. I am most grateful to the noble Lord, Lord Bradley, for co-signing my amendments. There is a role in recognising that the allied healthcare professionals are the third-largest part of the workforce—the workforce is not just doctors and nurses—and are critical to the long-term plan for the NHS. They work across the health and social care boundary and out into the community. They are integral—physiotherapists in particular—to primary care, and speech and language therapists are essential for children and young people, particularly those with communication difficulties, and that of course includes those with autism and learning difficulties.
I also recognise, though, the problem that you cannot have everybody listed on a board and everybody wants their own so-called representation on it. It will be important that the terms of reference and the metrics by which the function of the board is measured and compared are very clearly laid out, to make sure that there is appropriate consultation at all times with those who are on the receiving end of healthcare, and that people such as allied healthcare professionals are appropriately involved in decisions for the patient groups on which they can have a major impact. Quite often they have a much more major impact than medicine or nursing will do in terms of a patient’s long-term quality of life, and rehabilitation in particular.
So I hope that the Government have listened to this debate and in particular will heed the important warning from the noble Baroness, Lady Thornton, in opening this debate and in the content of the amendments that she has tabled.

Lord Mawson: My Lords, I spoke on Tuesday about the structure that my colleague Paul Brickell, a Labour councillor in Newham at the time, and I, wrote for the then Government Minister Hazel Blears  for the new company that would deliver the Olympic legacy in east London. I also described some of the key people who were invited to be directors of this company, with a clear vision and narrative, focused on delivery.
In east London live people from every nation on earth. Indeed, we did some research and we thought Greenland was not represented—but then we found a family in Newham that was from Greenland. Clearly, we could not have a representative from every nation on the Olympic Park Legacy Company, the OPLC—it was not possible.
At that time the noble Baroness, Lady Ford, was chosen as a Labour Peer by a Labour Prime Minister to be the chairman of the board. She was a very experienced player in the regeneration world from Scotland, not east London. I think that at the time she was a little embarrassed that I, an east Londoner, was not chairing it, given all the early work we had done on helping the east London Olympics happen. But I was not a Labour Party member and therefore could not carry the then Government with me, while she could. I was not concerned about this. My colleagues and I in east London were concerned about whether she had the knowledge and skill that could add real value to this important project and the public sector organisation that had been created. She was excellent and had an objectivity I could not possibly have.
We needed both things on the board: deep, local, practical experience and objectivity. I was asked to chair the Regeneration and Community Partnerships Committee, I think because she thought I knew quite a lot about these local issues and delivery, was trusted by local people and had a track record of delivering in place and in local neighbourhoods. Because my colleagues and I had delivered real projects with the local population, we did not know one thing about the place and neighbourhood: we knew, in depth, many things. It was all about finding the right experienced people, not those who said they represented something or somebody. The mayors of Newham and Hackney were there because they were impressive Labour leaders in east London who were turning around troubled local authorities.
I was asked to join the OPLC board as a person with deep, long-term roots in both a place—east London—and a neighbourhood, Bromley-by-Bow. I could speak and reflect back to the board not one thing—say, the environment—but also health: we were responsible for 43,000 patients. I had also been a Mental Health Act manager for quite some years locally. I think the noble Baroness chose me because I had deep and wide experience of the people, place and local neighbourhoods, and because of the practical work we had done in east London over quite some time—three decades, actually. It was about practical experience of place and neighbourhood and delivery. It was not about a person who thought he or she was representing one group or another, or a particular topic.
Experienced people bring many things to the board with them. I worry about the disabled person on a board who thinks they can talk only about disability issues—this is very condescending—or the young person who can talk only about young people’s issues. They can talk and have views on everything; it is about  finding the right-quality person. However, they must have in-depth knowledge of what is actually going on locally and a deep understanding of the practical issues surrounding delivery. This is absolutely crucial.
There is a wider problem with some representatives on committees and structures, because they represent other agendas and they have mixed loyalties. They cannot focus on the task of the board because they have mixed loyalties elsewhere. They do not therefore prioritise the needs of the organisation they are sitting on. There is a lack of clarity about this, and I suspect we will all have experienced this on boards we have sat on. We need to get very clear about these democracy and delivery issues—what I call “the two Ds”. I have listened to a lack of clarity around these issues from successive Governments in recent years. We must get this clear if the new NHS structure is to really deliver the transformation we all now want to see and to deal with the health inequalities we rightly all discussed this morning.

Baroness Harding of Winscombe: My Lords, I too spoke on Tuesday about my concerns about listing the specific membership for the NHS England board. I have similar concerns to those that the right reverend Prelate and the noble Lord, Lord Mawson, have just set out. However, there is a slight difference with this issue, in that the core purpose of an integrated care board is to integrate. So I recognise the very real concerns that noble Lords across the Committee have mentioned about the importance of being able to hear the voices of all the different elements of our health and care system, to hear patients’ needs loud and clear and to make it a board that genuinely works, as the noble Lord, Lord Mawson, has just set out.
I offer a small suggestion, building on what my noble friend Lord Hunt has said: in the drafting of this Bill, we should think more about what we want the integrated care boards to do—that is, their duties, and we have already had long and important debates on mental health and health inequalities—and how we will measure whether or not they deliver on those duties, and less on specifying in a lot of detail how they will do it.
That is why I find it hard to support the amendments, although, again, as I did on Tuesday, I very much understand and support the sentiment behind them.

Baroness Walmsley: My Lords, like the noble Baroness, Lady Thornton, I shall start with those who I think should not be on the board before I turn to those who I think should. To a great extent I support the noble Baroness’s Amendment 29, but with a small caveat that, if she wished to press it, might require a bit of redrafting. I will explain.
Additional provider medical services are very useful in many areas to fill gaps in primary care capacity. They may provide additional services from which other NHS primary care services have opted out, such as out-of-hours services or enhanced services beyond the capacity of local NHS GPs to deliver. In some areas they have taken over primary care services where NHS GP practices have become too small to be viable or all the partners have retired.
Some APMS services are commercial businesses with a responsibility to their shareholders to make a profit, and I do not think these should be on the board. However, some APMS contracts go to NHS entities, and I would not want to exclude those. Of course, we must remember that for many years GP practices have also been small businesses, sort of, operating within the umbrella and ethos of the NHS. They too need to clear their costs or they will close down.
That is all well and good. However, if the Government are serious that they want to exclude private sector interests from ICBs, they must surely agree to include in that ban non-NHS entities that hold APMS contracts. A failure to accept the amendment of the noble Baroness, Lady Thornton, must surely make us a little suspicious about the Government’s claim that their amendment inserted in another place would successfully exclude private interests from the board.
Amendment 29 would extend the range of those involved in commercial enterprises from being members of the board of an ICS beyond those that we have just discussed in relation to the noble Baroness’s Amendment 28. Amendment 29 would specifically exclude NHS GP practices and voluntary or not-for-profit organisations from the ban. There are many types of organisations that would be included in the ban, although they could be heard on the board of the integrated care partnerships. Those include: pharmaceutical companies; providers of medical devices, equipment or premises; people who own care homes; and many other essential services without which our NHS could not survive. However, their importance should not entitle them to influence the constitution, strategy or commissioning principles of the board of the ICS. They are important providers that will be appropriately involved in planning at other levels, but they should not be able to steer fundamental decisions without the suspicion that they might have a commercial interest in such decisions. Indeed, the ban proposed in the amendment would protect such companies from such a suspicion, so perhaps it would be welcomed by them.
Turning to those who should be on the board, I will not repeat what the noble Baroness, Lady Hollins, said in introducing her amendments, because she has done it extremely well, particularly emphasising the impact of integrated services on people with learning difficulties and people with autism and how they could benefit from better integrated services if we got it right. So, I support her amendments.
I turn to Amendment 37, to which I have added my name to those of the noble Baroness, Lady Thornton, and the noble Lord, Lord Patel, for the following reasons. According to the Explanatory Notes, each ICB and its partner local authorities will be required to establish an integrated care partnership, bringing together health, social care and public health. The constitution of the ICB as it stands in the Bill specifies that the board must include only a minimum of three types of people who the Government clearly believe are essential to the effective operation of the board. They are someone from NHS health trusts or foundation trusts, someone from primary care, and someone from one of the local authorities in the area. If it is okay to prescribe these members, would it not also be wise to  prescribe a few other key people with appropriate knowledge in order to achieve the ICB’s objectives of bringing together health, social care and public health? This amendment therefore suggests five other nominees—not 15, bearing in mind the Government’s wish to keep the ICB to a manageable size. But given the powers of the board, I would think it essential to have people nominated from mental health, public health, social care, health trade unions, patients and carers to bring their knowledge to strategic decisions.
If the board is to comply with the ambition of parity of esteem for physical and mental health—which we talked about two days ago—it will be important to have someone with the knowledge of how mental health services are working, as my noble friend Lady Tyler emphasised. Public health is a very particular discipline, the importance of which has been amply shown during the pandemic, which also has a vital role to play if we are to improve the health of local people and level up inequalities. Social care provision should never be separate from or subsidiary to health, as it is intrinsic to the functioning of health services in every area, so it is inconceivable that any ICB should ever be without someone from that sector.
The NHS is a people business, which is why those who deliver the services and the patients who are on the receiving end should have a voice at the top. Similarly, those thousands of unpaid carers, without whom vulnerable people would use up more of the NHS’s scarce resources than they currently do, should be represented at the very top of these new organisations. Their contribution to the efficient use of the board’s financial resources is crucial.
If the objective is to encourage more integration and collaboration, how could it be right not to have these additional five or six groups of people helping to make the strategic decisions? If that is not the case, as has been said by other noble Lords, the board could be dominated by the large acute hospitals and primary care, and the integration objective of the Government, which I endorse, would fail. I look forward to the Minister’s reply.

Lord Kamall: My Lords, this has been an excellent and wide-ranging debate, and I really am grateful to all noble Lords who tabled amendments today.
With your Lordships’ leave, I turn first to Amendment 18 in the name of the noble Baroness, Lady Thornton. This amendment would mean that the relevant ICB and ICP would need to be consulted before NHS England is able to provide support and assistance to bodies other than NHS bodies. The NHS has, under successive Governments of all political colours—indeed, since its foundation in 1948—commissioned care from various sectors to help it be more responsive to patients’ needs, and particularly to help deliver the commitments set out in the NHS constitution.
The vast majority of NHS care has been—and will rightly continue to be—provided by taxpayer-funded public sector organisations. But experience before and during the pandemic has demonstrated how important it is for NHS England to have the power, as the Trust Development Authority currently does, to provide  support and assistance to any providers of services on behalf of the NHS. This will ensure that independent providers can, if necessary, be commissioned to provide important additional capacity where needed.

Baroness Thornton: I really rather hoped the Minister would not go into whether or not I was suggesting that we should or should not be using private services. This is about who commissions services; this is not about who provides services. In my opening remarks, I said that a variety of providers is exactly what we have and will continue to have.

Lord Kamall: I thank the noble Baroness for that clarification.
The amendment seeks to exclude individuals whose GP practices hold an alternative provider of medical services, or APMS, contract from being a member of an integrated care board. While APMS contracts may not be appropriate for all GPs, they offer the ICBs, as commissioners, greater flexibility than other general practice contract types. As the noble Baroness, Lady Walmsley, acknowledged, the APMS framework allows commissioners to contract specific primary medical care services to meet local needs. APMS contractors include some private and third sector social enterprises and GP partnerships, which provide outreach health services for homeless people, asylum seekers and others. It is quite clear that none of this diminishes the commitment to ensure that care is provided free at the point of use, paid for by taxpayers.
All contract holders providing NHS core primary medical services are subject to the same requirements, regulations and standards, regardless of the type of contract. The Care Quality Commission, as the independent regulator, ensures that all contracts meet these standards.
Some GP partnerships concurrently hold a general medical services contract for core medical provision, as well as an APMS contract. Some individual GPs provide services for a range of practices. The concern is that this amendment would exclude GPs working for one or multiple practices which operate under APMS contracts from being members of the ICB.
NHS England’s draft guidance states that nominated members of an ICB will be full members of the unitary board, bringing knowledge and a perspective from their sectors, but not acting as delegates of those sectors.
This amendment would prevent some individuals being on integrated care boards, based on what type of NHS GP contract their practice holds. This could limit the ability of primary medical service providers to appoint an ICB member who understands the health requirements of the local population. This could reduce the diversity of GPs who could be appointed, based on their contract type. If we think of the unintended consequences, this may inadvertently exclude representatives with much-needed expertise in serving specific local populations and addressing their health needs.
Earlier, we talked about tackling inequalities. I feel very strongly that there are sometimes unintended consequences, where people think that they know better what is best for their communities. It would be unfortunate to exclude APMS contracts, or anyone  who had an APMS contract and who had the expertise needed for those communities that are not receiving an adequate service, or for poor, immigrant communities. This could go against the goal that we all want to see of tackling inequalities.
I now turn to Amendments 29 and 30. I am grateful to the noble Baroness, Lady Merron, and the noble Lord, Lord Davies, for bringing this issue before the Committee. I understand the interest in the role of independent providers in the integrated care boards. I also understand the concern across the Committee to ensure that independent providers, including companies seeking to produce health and care products, should not be appointed to the board of ICBs. We agree. Integrated care boards will be NHS bodies whose board membership consists of a minimum of individuals nominated by NHS providers, GP services and local authorities whose areas coincide with that of the ICB.
Although, as has been acknowledged, service provision by the independent and voluntary sectors has been an important and valuable feature of the system under successive Governments, it has never been the intention for independent providers as corporate entities to sit on integrated care boards, nor for an individual appointed to be there as a representative of an individual provider, in any capacity. People must therefore be assured that the work of ICBs will be driven by health outcomes, not profit. However, we recognise that this is a matter of concern to many noble Lords, as well as to the other place. We have been keen to put this beyond doubt, which is why we brought forward the amendment on this very point at Report stage in the other place. This amendment makes clear that no one may be appointed to an ICB who would undermine the independence of the NHS as a result of their interests in the private healthcare sector, social enterprise or elsewhere, including the public sector.
We expect this to prevent, for example, directors of or significant stakeholders in private healthcare companies sitting on ICBs. We expect it to prevent those with a significant interest in a private company producing, or seeking to produce, health and care products sitting on integrated care boards. We expect it to prevent lobbyists sitting on boards, and it would prevent anyone with an obvious ideological interest that clearly runs counter to the founding principles of the NHS and its independence sitting on the board of an ICB.
This test has deliberately been framed broadly to reflect the wide range of potential circumstances that would render someone unsuitable to sit on an ICB board. It has also been framed to require the appointing persons to apply an element of judgment, because we want what is best for the NHS at all times and that requires a degree of local flexibility. To guide this judgment and to make sure it is being applied appropriately, NHS England will have the power to issue general guidance on the appointment process. If necessary, we can introduce further requirements in connection with ICB membership through regulations.

Baroness Walmsley: I apologise for interrupting the Minister, but I want to ask him a question going back to Amendment 28 and the APMS contracts. If  we were to bring forward an amendment that made it very clear that we had no objection to NHS entities or not-for-profit organisations with APMS contracts being on the ICB, would he take a more friendly approach? It would just eliminate those that take profit out of the NHS.

Lord Kamall: I thank the noble Baroness for that suggestion and for trying to narrow the gap that there clearly is. If an amendment were put forward, we would look at it very carefully and consider the unintended consequences from the way it is drafted. We will consider it but, as I am sure the noble Baroness appreciates, I can make no promises at this stage.
I turn to the point made by my noble friend Lord Hunt of Wirral about how provider input in the work of an ICB will be reconciled with assessing both the suitability and performance of providers. As my noble friend correctly noted, each ICB must make arrangements on managing the conflict of interest and potential conflicts of interest, such that they do not and do not appear to affect the integrity of the board’s decision-making processes. Furthermore, each appointee to the ICB is expected to act in the interests of the ICB. They are not delegates of their organisations, but are there to contribute their experience and expertise for the effective running of the ICB—a point made most eloquently by the noble Lord, Lord Mawson, my noble friend Lady Harding and the right reverend Prelate the Bishop of London. It is important that this is about expertise, not the trust or organisation that they are taken from, or their skills and knowledge, as the noble Lord, Lord Mawson, said.
We are also keen to allow ICBs to develop their own governance arrangements, which best take their local circumstances into account. We want to give them the flexibility to learn and develop as their best practice evolves, so that other ICBs could learn from that best practice where there are concerns.
To support ICBs, NHS England is working with them to issue guidance and to develop and make clear our expectations of ICB leaders—expectations that have been reflected in the discussions and fantastic contributions from many noble Lords. For these reasons, I regret that the Government cannot accept these amendments at this stage. However, I hope I have given noble Lords such reassurance that they feel able to withdraw their amendments.
Turning to the membership of integrated care boards, I will begin with Amendments 27, 37, 38, 39, 40 and 41. I am grateful to all noble Lords who have brought forward these amendments today. I understand the interest from all sides in this membership. Schedule 2 sets out the minimum membership of the integrated care board; it will need to include members nominated by NHS trusts and NHS foundation trusts, by persons who provide primary medical services and by local authorities of areas that coincide with or include the whole or any part of the ICB’s area.
I take the point of the noble Lord, Lord Bradley, about mental health. I am sure he recalls the debate on Tuesday, when noble Lords felt very strongly about this. I have offered to meet many noble Lords from across the Committee who indicated that they want to see this parity with mental health, which they do not  believe is implicit at the moment, even if we believe that “health” refers to physical and mental health. Indeed, it refers to spiritual health in many ways. But we understand that we have to close that gap and I will make sure that the noble Lord, Lord Bradley, is invited to those meetings.
It is important for us that we are not overprescriptive, which is especially true of any membership requirement. Any extension beyond the proposed statutory minimum will risk undermining local flexibility to design a board, as my noble friends Lord Mawson and Lady Harding and others have said, in the most suitable way for each area’s unique needs, drawing on the best expertise, but not where they are from. It may also make the boards less nimble and less able to make important decisions rapidly if we overprescribe.
It is important to remind the Committee—I apologise if noble Lords do not appreciate the repetition—that we set a floor and not a ceiling. The ICB can appoint board members if it wishes. Local areas can, by agreement, go beyond the legislative minimum requirements. They will want to ensure they appoint individuals with the experience and expertise to address the needs and fulfil the functions. Areas are already doing this. For example, in south-east London the ICB is proposing to include three provider members—acute, community and mental health—and six place members, one for each borough. This approach is exactly how we want ICBs to use the flexibility available to them.
If, in time, some of the concerns expressed today by noble Lords become clear—such as issues being skated over, ignored or elbowed out by others with louder voices—we may need to add further requirements that relate to ICB membership, and there are regulation-making powers in place in Schedule 2 to allow the Secretary of State to do so. Furthermore, NHS England has the power to issue statutory guidance to ICBs. It could, for example, use this to recommend that each ICB should consider appointing a learning disability and autism senior responsible officer, as I know the noble Baroness, Lady Hollins, has asked for and has spoken about most eloquently many times, most recently in a debate a few weeks ago.
Taken together, our approach reflects our view and, I reiterate, the view of the NHS that we should not attempt to overlegislate for the composition of ICBs and instead let them evolve as effective local entities to reflect local need. Let us get the right balance between the top-down and bottom-up approach, and make sure that they are relevant to their local areas. I am afraid that these amendments are seen to take a different approach, by adding more people to the minimum requirements for the ICB, making them larger but not necessarily better. They also add additional complexity by introducing a significant number of members who are responsible for activity outside the NHS. We think these would be better represented on the integrated care partnerships, which have a broader remit. I come back to the point that it is about expertise, not which trust.
I will consider the comments made by noble Lords very carefully if some of the concerns have not been met, and will have future conversations, between this stage and the next, if they feel that we have not  addressed their concerns completely. I regret that the Government cannot accept these amendments. I hope that I have given your Lordships some, if not complete, reassurance and that noble Lords will feel able at this stage to withdraw and not press their amendments.

Baroness Thornton: My Lords, I thank the Minister for his detailed response. I was disappointed with the first remarks he made because he resorted to the mantra that the Government tend to go to when the question of private sector interests in delivering healthcare is raised by this side of the House. That is a shame, because the questions that we have raised are legitimate. In fact, his friends in the Commons accepted the conflicts of interest that could arise from private sector interests being represented on ICBs. We were seeking to make sure that that is watertight and there is no way of it changing. That is a legitimate question to ask.
I thank the noble Lord, Lord Patel, and the noble Baronesses, Lady Walmsley and Lady Meacher, for supporting Amendment 37, which is the key amendment in this group as to who may or may not be members of the board.
The noble Baroness, Lady Hollins, made a powerful case for the interests of people with learning disabilities and autism being represented. We know that where health systems make the health of people with learning disabilities a central priority, the whole health system benefits from it. That has happened in some places—for example, in Manchester—and it demonstrates how we improve the whole system. It is an important point.
My noble friend Lady Bakewell made the point about Centene and Operose, and that is partly why I put forward my amendment on APMS. The Minister may recall that we raised this matter in Questions a few weeks ago, when I asked him to write to me about what system had been used to give that contract to Centene, or Operose, in Camden, the area where I live. Having served on the CCG in Camden, I was aware of the importance of who runs primary care and of who the GPs in our surgeries are. Having right and proper people and organisations running our primary care was one of the criteria that you would use as a commissioner when you were looking at who was running, and who might wish to run, primary care and GP surgeries. I was involved in that process. As I learn about the history and background of this organisation now running primary care and GP surgeries in the UK, I do not think they are right and proper people to be doing that.
If this amendment does not serve the purpose of stopping that happening, I ask the Minister and the Bill team to reflect on what we might need to do to ensure that those from the private sector, social enterprises and charities whom we commission to run parts of our health service are right and proper people to do so. The remarks made in that regard by the noble Lord, Lord Hunt, were very interesting and useful, as they often are.
The noble Baroness, Lady Meacher, made the point about public health. That is the theme running through this Bill: the need for public health to be represented. She was also absolutely correct to bring us back to the  idea that clinical leadership is very important. Of course it is. The right reverend Prelate the Bishop of London asked some pertinent questions.
My noble friend Lady Pitkeathley raised the issue of social enterprises, which is close to my heart. I am the honorary secretary of the All-Party Group for Social Enterprise, which I helped to found 20-odd years ago. The APPG has just completed an inquiry, chaired by the noble Earl, Lord Devon, about the impact of Covid on social enterprises, which absolutely illustrates the points made by my noble friend and which I will share with the Minister when it is available.
The noble Baroness, Lady Finlay, made relevant points about Allied Healthcare. I think that the noble Baroness, Lady Walmsley, and I agree that the problem with APMS is that there is a lack of clarity and it is a bit of a loophole, and we need to look at it again. This may not be the Bill to do it in, but it might be.
With those remarks, and hopeful that the issue of who the members of the ICBs will be will run through our discussions for the next few weeks, I beg leave to withdraw the amendment.
Amendment 18 withdrawn.
Clause 7 agreed.

  
Clause 8: Exercise of functions relating to provision of services
  

Amendment 19 not moved.
Clause 8 agreed.
Clause 9 agreed.
House resumed.
House adjourned at 6.45 pm.